Swine flu response questioned in MIT paper

Specialists involved in the public health response said Doshi makes good points, but they also defended the measures taken during the outbreak last spring. Schools were closed only briefly, for example, and there were few cancellations of public gatherings. Public transportation was not shut down as might be in the case of a wider emergency.

"I think the response was very appropriate," Dr. Al DeMaria, state epidemiologist at the Massachusetts Department of Public Health, said. "It was very conservative. As you learn more about a virus, the recommendations change."

Dr. Paul Biddinger, medical director for emergency preparedness at Massachusetts General Hospital, said communicating the potential impact of a virus is always difficult.

"I think most people had assumed previously that a pandemic would always cause significant morbidity as well as significant spread of illness," he said. "People have been challenged with a pandemic that thankfully has not yet caused a significant change in morbidity from seasonal flu virus."

Doshi's paper says a surge in flu testing showed up in the spring only after international health officials declared a pandemic alert following reports of human transmission of swine flu in Mexico. US health officials followed with their own declaration of a nationwide public health emergency. That's when what Doshi calls a "concern bias" showed up: Anxiety was driving events more than the disease itself, he says.

"Behavior influences testing and testing influences our understanding of the response to the epidemic," Doshi said.

Longstanding pandemic plans were activated before the severity of swine flu was fully known, Doshi says. Fears about avian flu in 2005 may have primed public health planners to expect a global public health disaster, he said. While the avian flu was severe, it was not widespread. Swine flu, also known as H1N1, was easily spread, but is more moderate.

The new H1N1 subtype now appears to be more like the strain that circulated in the pandemics of 1957 or 1968, large outbreaks that had about the same number of deaths caused each year by seasonal flu, Doshi said. DeMaria of the state public health department agrees, but emphasizes that even ordinary seasonal flu can be serious.

"Just because it's not happening like 1918 doesn't mean people won't need health care. You still have to worry about surge capacity for a lot of sick people," he said.

Doshi recommends calibrating future responses to pandemics based on severity and spread.

"I think all of this [response was] based on an anticipation that had grown over the last four years that we are due for a very high consequence event. So the event was read looking for signs that made it fit the anticipation," Doshi said. "We need to have a little bit more foresight so we can have a flexible response and not only prepare for disaster."

Biddinger of Mass. General says that's not easy.

"Only in retrospect can we say what is a severe and mild and moderate level of pandemic," he said "It's really hard to do in real time."

Should H1N1 become more severe in the fall, Doshi said, preparing for disaster and accelerating vaccine development will be justified. If not, he said, "we need a new framework for thinking about epidemic disease."