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Discussion
While recent research has demonstrated the clinical importance of antivirals during the H1N1 influenza response, the role public health agencies in the management of these drugs at the local level has not been well studied. To the best of our knowledge, this is the first study to examine the antiviral activities carried out by LHDs during the H1N1 influenza response using a representative sample from a large geographic area. A major finding of this report is that, while the number of publicly purchased antivirals dispensed was limited in most communities (fewer than 10% of LHDs reported that more than 250 courses were dispensed in their jurisdiction), LHDs nevertheless drew on their previous work and engaged in a number of antiviral activities. LHDs successfully coordinated with the state health department to receive antivirals from the SNS, made decisions regarding when and where these antivirals would be dispensed within their community, determined which groups would be eligible for these antivirals, allocated and distributed antivirals to dispensing sites for the purpose of reaching target groups, developed systems for verifying eligibility for antivirals and tracking antiviral utilization, and provided guidance to the clinical community.
This study also documents specific challenges presented by the H1N1 pandemic that were faced, and overcome, by LHDs. Our research corroborates and compliments a recent qualitative investigation on this topic, conducted by National Association of County and City Health Officials (NACCHO) researchers. Using different methods, both studies find that LHDs had difficulty reconciling multiple sources and versions of antiviral guidance from state and federal agencies, and that this was a major challenge at the local level. This was not only the most commonly reported difficulty in our respondents; it was also one of the most likely to be characterized as "very challenging." NACCHO researchers aptly describe two potential contributors to confusion at the local level that appear to be supported by our findings. First, federal antiviral guidance during the H1N1 response primarily focused on clinical recommendations for antiviral use, and did not directly address how public stockpiles should be used. Second, clinical antiviral guidance changed during the course of the pandemic, which placed a greater emphasis on the use of antivirals for early treatment rather than post-exposure prophylaxis later in the pandemic.
Our research also demonstrates that the recommended uses and recipients of publicly purchased antivirals during the H1N1 response differed from what LHDs had anticipated in their pre-pandemic plans, and that this resulted in additional difficulties. During the 2009 H1N1 pandemic, antivirals were generally available through normal wholesale and retail markets; as a result, the State health department recommended that LHDs use publicly purchased drugs for the treatment of uninsured or underinsured persons and for communities experiencing shortages. For many health departments, this represented a significant shift in their pre-pandemic antiviral implementation strategy, which had focused on the use of publicly purchased antivirals for treatment of ill persons once retail supplies had been depleted and that had emphasized the role of antivirals in protecting healthcare workers and other first responders. As a consequence, LHDs revised their plans to support these new strategies, though implementing and communicating these strategies caused a strain on some local health departments and community partners.
Another outcome with particular relevance to public health planning is the effect of staffing and personnel shortages on the public health antiviral response. Among the nineteen agencies that cited staffing issues as a challenge during their antiviral response, nearly half found this to be "very challenging." These findings are consistent with the documented workforce reductions in local public health since 2008. As noted by one participant, current public health resources are insufficient for local health agencies to confidently deliver antiviral services in a "secure, accountable, consistent, and equitable manner" during a pandemic with a larger scope or greater severity. These concerns should be taken into account in the future development of antiviral and medical countermeasure plans and policies.
Public health systems researchers have noted that variations in availability of community resources and community preferences will influence how public health services will be implemented. In this study we observed great variability in the approaches used by LHD to manage publicly purchased antiviral drugs. It is expected that some of this variability is attributable to differences in the circumstances faced by LHDs (e.g. influenza illness incidence, community demographics, availability of antivirals in the retail market) while other variation is due to differences in disease control and prevention strategies. It is beyond the scope of this study to evaluate the effectiveness of different approaches; however, the findings may inform preparedness conversations regarding which variations in practice are seen as beneficial and adaptive and which areas might benefit from uniformity. State and local health departments, in California and elsewhere, can study these variations in practice and select models and promising practices to be included in their response planning.
Lastly, this report builds upon the Association of State and Territorial Health Officials (ASTHO) assessment of early experiences of state and territorial health departments in receiving and distributing antivirals from the SNS. Because state and local public health agencies serve different roles and functions in the antiviral response, there is a demonstrated need to document activities at both levels. Whereas the ASTHO research describes how publicly purchased antivirals were allocated and deployed from the SNS and then distributed and received at the state-level in California, our research tracks these antivirals into communities and further explicates how LHDs managed and directed this resource.
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