As the coronavirus threat has escalated in recent weeks, President Donald Trump has repeatedly compared it to the U.S. handling of the H1N1 swine flu outbreak of 2009.

In three press briefings and five tweets since March 1, the president has compared his administration’s handling of the coronavirus favorably to the way President Barack Obama’s team dealt with the H1N1 outbreak, which infected 60 million Americans. This comes after Trump spent weeks saying the coronavirus paled in comparison to the seasonal flu, a comparison we debunked over the weekend.

“Interestingly, if you go back — please — if you go back to the swine flu, it was nothing like this. They didn’t do testing like this. And actually, they lost approximately 14,000 people. And they didn’t do the testing. They started thinking about testing when it was far too late,” the president said at a press briefing on March 13.

Or this on March 15:

....The USA was never set up for this, just look at the catastrophe of the H1N1 Swine Flu (Biden in charge, 17,000 people lost, very late response time), but it soon will be. Great decision to close our China, and other, borders early. Saved many lives!

— Donald J. Trump (@realDonaldTrump) March 15, 2020

The president is wrong in multiple ways.

First, the swine flu did not kill 17,000 people, as Trump maintained in his tweet. Nor did it kill 14,000, the figure he cited days earlier. The U.S. Centers for Disease Control and Prevention has estimated that H1N1 killed about 12,500 Americans between April 2009 and 2010, far fewer people than typically die each year from the flu. (Trump has gotten this figure right on other occasions.)

Second, the president’s characterization of the government’s response does not match reality. If anything, the response to H1N1 was swift in comparison to the current administration’s handling of the coronavirus.

“I assume what he’s trying to say is somehow he’s doing a much better job,” Kathleen Sebelius, secretary of health and human services under Obama, said in an interview Wednesday. “I just find that totally baffling. Anybody who looks at the comparisons very quickly understands that this is not the case.”

From First Case to Approved Test: Two Weeks

Though the H1N1 virus had begun spreading in Mexico, the first case in the United States was detected on April 15, 2009, in a 10-year-old patient in California. Two days later, CDC laboratory testing confirmed a second infection in an 8-year-old also living in California. Within one week, the CDC had activated its Emergency Operations Center to respond to what it had identified as an emerging public health threat.

Before the end of April, the government had declared a public health emergency and started releasing medical supplies and drugs from the CDC’s Strategic National Stockpile. “The real-time PCR test developed by CDC was cleared for use by diagnostic laboratories by FDA under an Emergency Use Authorization (EUA) on April 28, 2009, less than two weeks after identification of the new pandemic virus,” the CDC notes on its website.

Sebelius remembers that date well. It was the day she was sworn in as HHS secretary.

The test developed by the CDC was created quickly. It was accurate. And it was shared with governments around the world, she said. “The capacity of CDC at that point to make and develop and quickly turn out a test was vastly different than what we saw occurring” with the coronavirus, Sebelius said.

In an interview, Dr. Tom Frieden, who was CDC director under Obama, said testing for H1N1 and the United States’ willingness to share its test with other countries was a success. “I traveled all over the world and for years afterward even very hostile governments were saying thank you for sending it to us.”

Coronavirus testing, on the other hand, remains mired in delays. Though the first person in the United States was confirmed to have the virus on Jan. 20, a series of problems have kept testing out of reach for many patients with telltale symptoms of the virus. The CDC designed a flawed test for COVID-19, then it took weeks to figure out a fix so state and local labs could use it, ProPublica found. Trump said on March 6 that “anybody who wants a test gets a test,” but many doctors, patients and public health leaders say that is not the case.

On Wednesday, Ohio Gov. Mike DeWine, a Republican, said: “Testing is limited. It will, in all likelihood, remain limited.”

#COVID19 Testing: Testing is limited. It will, in all likelihood, remain limited. But please, do not fixate on testing. The vast majority of Ohioans who have symptoms do not need to be tested for the virus. If you are feeling symptoms, you should act like you have it.

— Governor Mike DeWine (@GovMikeDeWine) March 18, 2020

Vaccine Successes and Weaknesses

Almost from the day the H1N1 strain of flu was identified, researchers set out to develop a vaccine for it. Six days after the first case was identified in April 2009, the CDC began working to develop a candidate vaccine virus. Clinical trials began in July. And on Sept. 15, the Food and Drug Administration approved four 2009 H1N1 influenza vaccines. The first doses of the vaccine were available in October, and by December, 100 million doses were available to be ordered.

The vaccine production didn’t go as smoothly as officials had hoped. In October, the CDC and Frieden were called to task about the pace of the manufacturing process.

“We are now in a period where the vaccine availability is increasing steadily but far too slowly,” Frieden said at a press briefing in October 2009. “It’s frustrating to all of us. We wish there were more vaccine available. ... Manufacturers are working hard to get as much vaccine out safely as possible. The vaccine strains of the virus grow and that’s how we develop vaccine. Even if you yell at them, they don’t grow faster.”

Once it was manufactured, the vaccine was distributed widely. CDC arranged for 126.9 million doses of the vaccine to be shipped to tens of thousands of medical providers. All told, about 81 million U.S. residents were vaccinated, and the strain is now a regular part of annual flu shots. I remember waiting in line with my family at a school in Bergen County, New Jersey, to get my shot. The line was long but orderly.

“The biggest problem with the H1N1 [response] is that the vaccine didn’t come on time,” Frieden said.

There is no vaccine yet for the coronavirus. The disease is novel and appears to behave differently than the flu, so it will likely take longer to develop a vaccine, which would not be the fault of the Trump administration. The first patients in a clinical trial of a vaccine were given shots this week. But Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, cautioned that the process may take a year or more.

“We’re close to starting a phase 1 trial to determine safety,” Fauci said recently on CNN. “We’re going to do that in about one and a half to two months. But that doesn’t mean you have a vaccine. In order to get a vaccine that’s practically deployable for people to use, it’s going to be at least a year to a year and a half at best.”

If Trump wants to learn from H1N1, he could start readying manufacturing capabilities right now, so once the coronavirus vaccine is proven to be safe and effective, there won’t be any delay.

Coronavirus Is Not H1N1

The coronavirus that causes COVID-19 is different from the H1N1 swine flu.

Though we are still learning a lot about the coronavirus, the biggest difference appears to be the difference in mortality between the two viruses. The death rate of H1N1 was just 0.02%. By comparison, the data to date seems to indicate that the case fatality rate (the number of reported deaths divided by the reported cases) for the coronavirus is 3% to 4%, the World Health Organization reported this month. Researchers have acknowledged that number may fall over time.

Moreover, the coronavirus appears to spread more easily than H1N1. What that means is that each person who is infected will likely infect more people than a patient who had H1N1.

And who is affected by the coronavirus is also different from the patients most susceptible to death from H1N1. Deaths from COVID-19 have been concentrated in those over age 65. By comparison, H1N1 struck children and young and middle-aged adults the hardest.

It remains unclear how many people will ultimately become infected by the coronavirus, but experts at Harvard have said 20% of adults is a conservative estimate based on other pandemics and its spread so far, though many will not be tested or will have only mild symptoms. Because of its virulence, that could overwhelm hospitals and has prompted widespread calls for people to stay home. In 2009, those calls were largely confined to schools that had outbreaks of H1N1.

Lessons From H1N1

Both Sebelius and Frieden said one of the key lessons from H1N1 was the need for clear and honest communication, something they both faulted in the current coronavirus response.

Obama’s administration reacted with alarm as cases of H1N1 were initially reported. Trump, by comparison, repeatedly reassured the public that everything was under control.

“From Day 1, [Obama] said: ‘We will be led by the facts. We need to tell people what we know and what we don’t know,’” Sebelius said. She said she and her team held twice-a-day press conferences to do that.

At one point, in June 2009, Obama invited experts who helped respond to the 1976 swine flu outbreak to a private meeting at the White House. He wanted to know “what went right and what went wrong. What do we need to learn, how do we need to do this,” Sebelius said.

“I haven’t seen any of that go on with this,” she added, referring to the coronavirus.

Asked to rate his response to the crisis on a scale of 1 to 10, Trump said on March 16: “I’d rate it a 10. I think we’ve done a great job. ... We were very, very, early with respect to China. And we would have a whole different situation in this country if we didn’t do that.”

Frieden said he’s been troubled by the fact that CDC officials haven’t played a more visible role in the crisis response. Instead of briefings led by CDC leaders, Trump, Vice President Mike Pence and others brief the media each day.

“The biggest concern that I see now is the lack of CDC at the table when decisions are being made and at the podium when they’re being communicated,” Frieden said. “That is a really big mistake. That has not happened before.”

“This is not the way to run a railroad. It might get better. We’ll see. I hope so. We all want them to succeed.”

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