The Public's Response to the 2009 H1N1 Influenza Pandemic

SteelFisher GK, Blendon RJ, Bekheit MM and Lubell K New England Journal of Medicine, 19 May 2010-05-28

The authors of this paper examined the reported views and responses of the public in the United States to the 2009 A(H1N1) influenza pandemic and relevant national public health recommendations. They did this through a comprehensive review of available data from national public opinion polls conducted by telephone in the USA between April 2009 and January 2010. The sources of data were 20 telephone polls.  Eight of the polls were conducted as a series with public health intent by the Harvard School of Public Health through cooperative agreements with the Centers for Disease Control and Prevention (CDC) and others.  In addition there were 12 other polls undertaken by a variety of news agencies and one other university.  The authors examined the extent to which people reported specific behaviours during three periods: the early months of the pandemic (when no vaccine was available); at the time of the initial delayed release of vaccine to high-risk and other target groups; and after the vaccine was widely available. In addition, they examined the reasons why Americans reported that they did not get vaccinated and reviewed the public's view of the government's response to the pandemic.

The review found that early on, when no vaccine was available, a majority of Americans reported they adopted two central public health recommendations. Nearly two thirds of respondents stated that they or someone in their family had begun to wash their hands or clean them with sanitizer more frequently. Also just over half said they had made preparations to stay at home if they or a family member got sick. Later as discussions on vaccine began and when vaccine started to become available (July to October)  the American public was divided over whether they would get vaccinated. About half said they expected to receive the vaccine but a higher percentage of parents (around two thirds) said they expected to get their children vaccinated.  There were two major reasons why people said they would not or might not get themselves or the children vaccinated, concern about its safety and the belief that it was not needed. The authors therefore suggest that people appeared to adopt a trade-off between the risk of the illness and  any perceived risk associated with the vaccine. They suggest that, in the event of a future influenza pandemic of similar severity a substantial proportion of the public may not take a newly developed vaccine because they may believe that the illness does not pose a serious health threat, because they (especially parents) may be concerned about the safety of the available vaccine.

ECDC Comment (31st May 2010):  The United States authorities are prescient in having telephone surveys readily available for monitoring attitudes and reported responses to a range of health crises. They are also fortunate in only having two languages to work with.(1)  The American surveys are organised by the Harvard school of Public Health and the US CDC. They have been conducted by telephone and can be deployed and analysed remarkably quickly. In this pandemic the first simple survey results were available by late April 2009.(1,2)    Another advantage of this arrangement is that they can monitor trends in reported attitudes (which are more reliable than absolute values) and survey questions can be adjusted and added to over time as needs arise.[2]   This is crucial in view of the role that the public plays in mitigating illness and in seeking related medical care, vaccines and antivirals in a pandemic.  In the United States these arrangements are also essential as telephone polls are the main mechanism by which vaccine coverage is monitored in the USA.(3)  There  are some European countries that have undertaken similar repeated  ‘tracking surveys’,  monitoring public attitudes concerning public responses to the pandemic and vaccination. But the results of these are usually not published.  There is also a single detailed Eurobarometer Survey.

The seeming trade-off in the mind of the public observed by the authors, that is between benefits and perceived risks of vaccination is important. One of the distinct features of the public response to this pandemic has been informal reports of significant public change in attitude to the pandemic and a surge in desire for vaccination in a number of countries (Canada, Finland Netherlands and Romania) following reports in the media of deaths due to the pandemic virus in young healthy adults.  As reported in the American review concern over side-effects of the vaccine has persisted despite the positive pharmacovigilance reports such as from the European Medicines Agency.(5)  

1. Blendon RJ, Koonin LM, Benson JM, Cetron MS, Pollard WE, Mitchell EW, et al. Public response to community mitigation measures for pandemic influenza. Emerg Infect Dis [serial on the Internet] 2008 May [date cited].
2. Harvard School of Public Health  - Press Release.  Pandemic polls series with Centers for Disease Prevention and Control. February 2010
3. Centers for Disease Control and Prevention.  Interim results: influenza A (H1N1) 2009 monovalent vaccination coverage — United States, October–December 2009. MMWR Morb Mortal Wkly Rep 2010;59:44-8.
4. European Commission Eurobarometer Influenza A(H1N1)  analytic report March 2010
5. European Medicines Agency’s European Pharmacovigilance Reports