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Trump Misleads on H1N1 Swine Flu Testing

Deflecting attention from the rise in COVID-19 cases, President Donald Trump has repeatedly said the Obama administration “stopped testing” during the H1N1 pandemic. He’s correct that individual reporting was halted after a few months, but some testing did continue — and the two viruses are very different, making the comparison misleading.

Whereas pandemic H1N1 influenza was no worse than the seasonal flu, and testing did not play much of a role in controlling the spread of the virus, COVID-19 is far more deadly, and testing is critical for contact tracing and isolation.

Trump first mentioned the Obama administration’s decision to halt reporting of individual H1N1 influenza cases at a July 13 roundtable on law enforcement, when the president was asked by a reporter whether he would acknowledge that coronavirus cases were rising because of increased spread of the virus, and not just because of testing, as Trump has frequently claimed.

In response, Trump falsely said that the U.S. has one of the lowest COVID-19 mortality rates — it does not — and then proceeded to say that President Barack Obama and Vice President Joe Biden “stopped testing” during the 2009 pandemic. 

Trump, July 13: If you know, Biden and Obama stopped their testing; they just stopped it. You probably know that. I’m sure you don’t want to report it. But they stopped testing. Right in the middle, they just went, “No more testing,” and on a much lesser problem than the problem that we have, obviously with respect to — this is the worst thing that’s happened since probably 1917. This is a very bad — all over the world. It’s 188 countries right now.

The next day at a press conference in the Rose Garden, Trump brought it up again, this time specifying that he was talking about H1N1.

Trump, July 14: And if you look at the job [Joe Biden] did on swine flu — I looked at a poll — they have polls on everything nowadays — and he — they got very bad marks on the job they did on the swine flu, H1N1. He calls it “N1H1.” H1N1. He got very poor marks from Gallup on the job they did on swine flu. And they stopped, very early on, testing. They totally stopped it. They just said, “Stop.”

As we have written, the president has made inapt comparisons between COVID-19 and H1N1 before, and the polling claim is trumped up. No polls specifically evaluated Biden’s performance in the 2009 pandemic, but the Obama administration received moderately good marks at the time.

Trump’s latest H1N1 claim appears to stem from a Fox News article that Press Secretary Kayleigh McEnany shared in a July 11 tweet.

“Under Obama/Biden, ‘the CDC abruptly advised states to stop testing for H1N1 flu, and stopped counting individual cases,’ she said, quoting the news story. “Meanwhile, @realDonaldTrump⁩ has tested 40 million+, leading the world in testing!”

The White House did not respond to our inquiry for more information.

Different Viruses, Different Roles For Testing

It’s true that the Centers for Disease Control and Prevention stopped having states report H1N1 cases in late July 2009, a little more than three months after the first U.S. pandemic influenza virus cases were identified in April. 

But the CDC did not “totally” stop testing, since some testing continued for surveillance purposes and for select patients. And Trump is omitting relevant context as to why the CDC made that decision — and how the circumstances are different this time around with COVID-19.

The CDC explains in an archived webpage that individual cases of H1N1 pandemic influenza were monitored early on to track the spread of the disease, but as the virus became widespread, the case counts “became an increasingly inaccurate representation of the true burden of disease” as many people were mildly ill and did not seek treatment and the vast majority were not tested.

“CDC recognized early in the outbreak that once disease was widespread,” the website continues, “it would be more valuable to transition to standard surveillance systems to monitor illness, hospitalizations and deaths.”

On another webpage, the CDC says that individual case counts became “increasingly impractical and not representative of the true extent of the outbreak” because only a small proportion of patients were tested for influenza, “so the true benefit of keeping track of these numbers is questionable.” 

The webpage added that the “extensive spread” of the virus made it “extremely resource-intensive for states to count individual cases,” and that the agency would continue to track H1N1 hospitalizations and deaths.

Dr. Anne Schuchat, then-director of the National Center for Immunization and Respiratory Diseases, and now principal deputy director of the CDC, also explained the change in a July 24, 2009, press call, noting that at that point in the pandemic there had been 43,771 laboratory-confirmed cases of H1N1 influenza and 302 deaths in the U.S.

“But as we’ve been saying, that’s really just the tip of the iceberg, so we’re no longer going to expect the states will continue this individual reporting and we’re going to transition to other ways of describing the illness and the pattern,” she said. “We believe there have been well over a million cases of the new H1N1 virus so far in the United States.”

The decision followed the World Health Organization’s July 16 announcement that it would no longer issue global reports on the number of confirmed H1N1 cases, given the difficulty of testing such a large number of cases, and the fact that such counts were “no longer essential in such countries for monitoring either the level or nature of the risk posed by the pandemic virus or to guide implementation of the most appropriate response measures.”

The CDC would go on to report estimates of the number of H1N1 cases, hospitalizations and deaths in the U.S. throughout the pandemic, specifically trying to use statistical methods to account for underreporting.

Dr. Nicole Lurie, a physician and assistant secretary for preparedness and response during the H1N1 pandemic, told us the comparison to COVID-19 is “really misleading.”

“The role of testing in those two diseases is terribly different,” she said in a phone interview. “In flu, the major reason that they tested people at the beginning of the epidemic was so that you would know when influenza arrived in different communities.”

But once the virus had arrived and established itself, she said, doctors could “make a pretty good presumption” that people with flu-like symptoms had flu.

“Individual testing was no longer needed because it was just wasteful and provided no additional information,” said Lurie, who is now a strategic advisor to the CEO of the Coalition for Epidemic Preparedness Innovations, a nongovernmental organization dedicated to developing vaccines to stop epidemics, including COVID-19.

Dr. Amesh Adalja, a senior scholar at the Johns Hopkins University Center for Health Security, also told us that testing for H1N1 was not particularly valuable because the virus was so prevalent, and there was a readily available therapy — Tamiflu and other similar antivirals, which also work on seasonal flu.

“The testing was onerous,” he said, noting that a confirmatory diagnostic test could take days to come back with results. “The rapid tests were not very accurate, and we had an antiviral, and we didn’t want people to refrain from giving them an antiviral because they were waiting for a test or the test result was negative.”

There are no FDA-approved drugs to treat or prevent COVID-19, although research suggests the investigational drug remdesivir may shorten the time to recovery and the steroid medication dexamethasone may improve survival of critically ill patients.

The situation with COVID-19, Lurie said, is very different, because testing is still critical for understanding where the coronavirus is spreading and because it’s an essential public health tool for controlling the virus.

“Testing triggers isolation and contact tracing,” Lurie said of the COVID-19 situation. “So for disease control, it’s really important to test. That was not the case with flu.”

Critically, too, is the fact that pandemic H1N1 influenza wasn’t nearly as dangerous as COVID-19. While there is still debate about exactly how deadly the novel coronavirus is, most experts peg the infection fatality rate at around 0.6% to 1%. 

According to CDC estimates, the H1N1 pandemic infected 60.8 million Americans over a year, but led to just 12,469 deaths. That puts the infection fatality rate at 0.02%, or some 30 to 50 times less deadly than COVID-19.

“The mortality rate of H1N1 pandemic virus was lower than seasonal influenza,” Adalja said. “We found that out very quickly, and that also influenced how we dealt with it.”

As of July 16, there have been nearly 3.5 million COVID-19 cases and more than 137,000 deaths in the U.S., per the Johns Hopkins University COVID-19 tracker — although both numbers are likely underestimates.

Dr. Tom Frieden, president and CEO of the global health initiative Resolve to Save Lives and head of the CDC during the H1N1 pandemic, also noted these differences in a statement given to FactCheck.org.

“Testing data are only as useful as the actions they inform — and in the case of the 2009 H1N1 and current COVID-19 pandemics, they have very different roles,” he said. 

Because the 2009 H1N1 strain was not more dangerous than a typical seasonal influenza, which has led to between 12,000 and 61,000 deaths annually since 2010, most people did not seek care or get diagnosed. As a result, he said, for every laboratory confirmed case from April to October 2009, there were around 79 cases that went undiagnosed.

“So it was never practical to identify cases, trace their contacts, and ask exposed people to quarantine,” Frieden said, adding that by July, collecting national data was no longer important because the data “were not a good measure of the scale of the epidemic, nor actionable for contact tracing.”

COVID-19, on the other hand, is “qualitatively different,” he said, since it does lead to severe disease in many cases. “Although not everyone who contracts the virus seeks and receives testing, a higher share do, so testing data is a more useful indicator of the direction of the epidemic,” Frieden said.

“When someone compares these two pandemics and says – correctly – that the 2009 H1N1 pandemic was ‘a much lesser problem than the problem that we have,’ they are inadvertently explaining exactly why reporting of testing data is so much important now than it was then,” he said. “The current pandemic is much more severe, which is why we have used public health and social measures to box in the virus, and testing is a key component of that.”

Adalja said he thought the CDC’s decision to stop individual reporting for H1N1 was reasonable. “We didn’t have molecular diagnostic testing as widespread in 2009 as it was in 2020, and the rapid tests just weren’t accurate enough,” he said, “so we knew we were undercounting.”

Lurie said anyone who makes the H1N1 comparison to the coronavirus doesn’t understand very much about COVID-19. “It’s kind of like comparing oranges and basketballs,” she said. “They’re both orange, but that’s about as far as you get.”

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