Will California remember the lessons of the COVID health emergency?

We got a lot right. But potential new threats are emerging -- even as counties face budget cuts that could sacrifice future preparedness.

Inside secret warehouses strategically placed around the state, California is storing a massive cache of vital medical supplies, including masks, gloves and life-saving medicines, seeking to be better-equipped than it was during the COVID crisis.

Four years after our lives were upended by the coronavirus, with a new viral threat looming, public health experts are asking: What else have we learned from the pandemic?

While California is much better prepared, health experts say a closer review indicates more testing, more sustained funding and stronger national leadership are needed if they hope to execute their well-made plans.

“We have learned a lot. We’re in a better position to deal with the next threat,” said Dr. Sarah Rudman, deputy health officer for Santa Clara County, which recorded the first COVID-19 death in the nation.

But potential new threats are emerging — even as counties face budget cuts that could sacrifice future preparedness. As a public health emergency wanes, attention fades also,  Rudman said.

So far, the public health risk of avian flu, or H5N1, is low. Of the four people who have contracted H5N1, three had exposure to dairy cows and one had exposure to infected poultry. All U.S. cases have been mild, and none were in California.

But the virus is spreading into multiple mammal species. Last week, the federal government reported 36 more avian flu detections in house mice, as well as four more cases in domestic cats. To date, 95 cattle herds across 12 states have been affected.

“It’s a red flag,” said Dr. John Swartzberg, clinical professor emeritus of infectious diseases and vaccinology at UC Berkeley. “It’s a very small risk, but there’s potential — and I don’t think we’re responding as robustly as we should be.”

The concern, said Dr. George W. Rutherford of UC Berkeley’s School of Public Health, is that the virus will accumulate genetic mutations that lets it jump from animals to people — and then spread.

Health experts see successes and failures:

California’s “SMARTER” Plan, announced in 2021, is a seven-part strategy that boosts preparedness. The “S” in the acronym represents access to shots; M, for masks; A, for awareness; R, for readiness; T for testing; E for education and R for Rx, or medical treatment.

In the early days of the pandemic, Bay Area hospitals and county heath clinics were so desperately low on medical supplies that they appealed to the public for donations of N95 masks, gowns and gloves. Under former Gov. Arnold Schwarzenegger, the state had spent hundreds of millions of dollars buying and storing supplies. But when the 2008 recession clobbered the state budget, they were given away to save on storage costs.

Now hospitals, skilled nursing facilities, dialysis clinics and medical practices that are part of a larger health system are required to build a 45-day stockpile of Personal Protective Equipment items like masks and gloves.

And the state has multiple “strategically placed” warehouses, in collaboration with the Strategic National Stockpile, which hold a cache of protective equipment, emergency pharmaceuticals and other supplies. The stockpile is rotated and updated to prevent expiration, according to the California Department of Public Health. For security reasons, the locations of the warehouses are secret. The department said costs for restocking the cache to replace items past their shelf life “depend on supply chain readiness, community needs, available funding, and will depend on the type and nature of specific events and incidents.”

“It’s a very good solid plan,” Swartzberg said.  “The people who put this together thought about the big things.”

“But there’s one big caveat: We’re not an island,” he said. “If we’re really well-prepared — but the U.S., in general, is not well-prepared — then it’s going to be difficult for us to carry out this plan.”

That’s because California must follow the guidance of the U.S. Centers for Disease Control, he said. And California doesn’t have the manufacturing capability to produce everything that it needs.

The federal government has worked with flu vaccine manufacturers to develop and test batches of H5N1 vaccines targeting different versions of the virus, according to STAT, the digital medical news site. About 10 million doses are being stored in bulk, according to David Boucher, director of infectious diseases preparedness and response for the federal government’s Administration for Strategic Preparedness and Response.

But with two doses needed per person, that would not go very far.  Manufacturing an avian flu vaccine, which uses eggs, takes longer than the mRNA system that was developed for COVID. It could disrupt production of the seasonal flu vaccine.

And experts like Rutherford worry about fighting an avian flu with an egg-based vaccine, because chickens could be lost.

And while the federal government has made efforts to try to bolster the stockpile of supplies, “there hasn’t been a lot of transparency. It’s hard to gauge the sufficiency of it,” said Jennifer B. Nuzzo, director of the Pandemic Center at the Brown University School of Public Health.

California businesses need more help navigating the recommendations or mandates of public health experts, said Swartzberg. At the peak of the pandemic, large corporations could afford private consultants, but smaller businesses could not.

Specifically, businesses lack expertise in how to optimize air exchange, handle exposures, conduct quarantines and isolation and communicate the importance of vaccination. They also need testing protocols for testing employees.

To speed economic recovery, businesses need easier access to capital or subsidies beyond the federal disaster loans, and also need mentoring to create new sales channels, according to a report from the Regional Small Business Development Center Networks of California.

“Just as we’re preparing the state’s government to handle the next pandemic, we should be preparing the state’s businesses and industries prepare for the next pandemic,” with better communication from state and federal health officials, said Swartzberg.

“They really wanted to do the right thing to keep businesses open,” he said.

Better surveillance and testing would alert us to the arrival of a lethal virus.

The CDC tracks overall levels of influenza A in sewage, but does not test for specific subtypes, like H5N1. Wastewater testing specifically for bird flu virus will scale up nationally this summer. The philanthropically funded WastewaterSCAN, an infectious disease-tracking sewage surveillance network led by Stanford University and Emory University in partnership with Verily Life Sciences, will monitor samples from 190 sites at treatment plants across 36 states.

Many California counties, including Santa Clara, Alameda and San Francisco, also track influenza A levels in wastewater, then test for H5N1 if they experience an atypical spike in influenza A activitiy.

While samples of retail pasteurized milk are tested, testing of animals for H5N1 is voluntary, except when cows are moved across state lines.

And there are few tests of people, in part because people who work on farms are reluctant to volunteer.  There’s another problem: The CDC is the only institution authorized to do an advanced confirmatory test, called PCR, testing in people with suspected avian flu, said Swartzberg.  This is reminiscent of the botched early days of the COVID pandemic, when a backup in CDC testing led to delays in case counts.

Finally, the U.S. Department of Agriculture has released only limited information about the genomic sequences of H5N1 samples, limiting research.

Funding cuts could undermine the state’s preparedness. Faced with a $44.9-billion budget deficit, Gov. Gavin Newsom has proposed cutting $300 million in public health funding.

This would not only shrink the California Department of Public Health but also local health jurisdictions, putting at risk over 1,200 jobs.  Santa Clara County, for instance, faces a $7 million to $10 million reduction in flexible funds that support pharmacists, lab staff, data scientist and community outreach experts.  It coincides with the ending of a major federal grant that helped it build essential infrastructure, like wastewater monitoring, data management and vaccine outreach.

“There are a number of lessons we learned from the COVID pandemic that put us in a much better position to deal with the next threat,” said Rudman. “But our ability to do so is in jeopardy.”

“What’s so tricky about pandemic preparedness is that we don’t know a lot about what will hit us next,” she said. “Except that it will be different from what hit us last.”