Revels, Reviews and Renewal: Looking Back, Looking Ahead

Ten years on, Y2K seems a distant memory. This year, computer glitches were far from the minds of most revellers as they marked the beginning of 2010 with the blast and blaze of fireworks. Instead, 2009 was the year of H1N1. It led health news coverage in the global media (Madison 2009; Branswell 2010) and was also one of the most common topics of general conversation, as reflected in posts to social networking sites (Backstrom 2009; @Abdur 2009).

In most countries, Google search volumes for H1N1 peaked in the early stages of the outbreak.¹ Canada, though, saw a second spike in October/November. I was not surprised to see the data. From chats with taxi drivers to exchanges with health experts, conversations during a trip to Toronto last fall all seemed to turn to H1N1. The balance was noticeably different at home in Denmark, in London where I was the week before and in Colombia where I travelled the following week. Ironically, the same trip also brought to my attention differences in public communications strategies regarding the pandemic. Before I left, I scoured a large number of government travel advisories. At the time, both Australia and the United Kingdom started their advice for travellers to Colombia with bold-font announcements about H1N1. They then went on to highlight the risk of violent attacks, kidnapping and other crime. Canada, the United States and Denmark reversed this order or did not mention H1N1 at all in their country-specific travel advice. (In the end, I received a warm welcome and my trip was entirely trouble-free.)

In this and much more serious ways, H1N1 tested existing communications protocols; stretched the boundaries of what we know about influenza, pandemics and how best to prepare and respond; and led to many new questions. While experience and the evidence base are growing, challenges existed at all levels, from GPs who cared for worried patients to the corridors of the World Health Organization's headquarters in Geneva.

The differences that I saw in my travels piqued my interest in how various juris-dictions were managing their H1N1 response. My colleagues and I at the International Health Terminology Standards Development Organisation in Copenhagen conducted an informal scan of vaccination policies and programs in mid-November 2009. We looked at government websites from European countries to identify when H1N1 immunization began, how vaccination was being done (e.g., through physician offices or public vaccination clinics) and which groups were being offered the vaccine. We also reviewed news stories posted on the websites of the country's largest-circulation newspaper and the national broadcaster in the first two weeks after vaccination began in the country. The approach was necessarily a convenience sample, albeit a fairly large one; it was limited to countries that had information in a language that at least one of us could read well enough to interpret short articles (Danish, English, French, German, Greek, Italian, Norwegian, Spanish or Swedish).

A key question that policy makers had to answer was whether or not to target priority groups for vaccination, and if so, which groups. Answers varied widely and often changed as immunization campaigns progressed. Technical data informed decisions, but other factors also swayed minds in many nations. Most, but not all, countries chose to target specific priority groups, at least initially. Healthcare providers were on the list almost everywhere. Children of different ages were sometimes in and sometimes out, as were pregnant women. There were also variations in which chronic conditions were included on priority lists. Decisions affected how much vaccine needed to be acquired, roll-out plans and much more.

Choices also needed to be made about how to distribute vaccines. Countries chose a range of approaches, including providing services through physician offices, mass vaccination clinics and targeted immunization programs. In Canada, while vaccines were distributed in a variety of ways, many jurisdictions used mass immunization clinics. Queues at these clinics became big news in several parts of the country. Friends who waited in line for shots also shared their experiences with me. (The winning war story: hours queuing with four young kids at a vaccination clinic that had no available toilet facilities.) “Is it the same elsewhere?” they asked.

Answer: yes and no. Our scan did find media reports of queues for vaccination clinics in other countries, but they were by no means universal. One reason may be differences in the uptake of immunization, including spikes in interest that took place during campaigns. Another is that some countries placed much less emphasis on open, mass vaccination clinics. Instead, several regions were able to identify and schedule appointments for patients who qualified for the vaccine. In the United Kingdom, for instance, the H1N1 vaccination program for high-risk patients was run within primary care. National protocols could be used to identify eligible patients in a general practice, incorporating information about a patient's medical history and past health problems that had been captured using standardized terminology. Many practices in Denmark were able to employ similar approaches.² The result at a personal level: rather than going to a clinic, a friend with a qualifying chronic disease was contacted by her general practitioner's office prior to the start of the vaccination program to schedule an appointment for her shot. Similar strategies were reported in Sault Ste. Marie in Canada, where the Group Health Centre has been an early adopter of electronic health records (Purvis 2009).

“N=1” personal experiences like those described above can help to trigger questions and new lines of inquiry, but broad data on comparative vaccination rates, the distribution of who received shots, their effectiveness, costs and benefits continue to emerge. Clearly, there are pros and cons to different approaches, some or all of which may depend on the context in which they are applied. Public health officials and epidemiologists, among others, have many important questions to address in the coming months and years. I hope that interesting results from their in-depth, thoughtful analyses of what went right and what went wrong in the pandemic preparations and response will appear in this journal's pages. And I hope that those analyses will help us to improve health and healthcare in the future.

To help steer the discussion and debate in Healthcare Policy/Politiques de santé, we are welcoming two new editors to the journal. Patricia Martens from the Manitoba Centre for Health Policy, University of Manitoba will be taking over from Rick Rogers in leading the journal's Data Matters column. Likewise, Mark Dobrow (based at the University of Toronto and Cancer Care Ontario) will be joining the editorial team as John Horne steps down. Please join me in thanking Rick and John for their stellar service over the past five years and in welcoming Patricia and Mark to the team.