Pondering How to Tell the World Swine Flu is a Pandemic

Source: Bloomberg.com Worldwide News
Date: 02 June 2009
Author(s): Jason Gale

The World Health Organization is caught between a virus and a hard place.

The agency, having spent the past five years alerting the world to the dangers of a pandemic, is now looking for a way to declare one without causing panic. WHO Director-General Margaret Chan and colleagues spent seven hours yesterday consulting experts on how to explain that swine flu is global, but not severe, said three people familiar with the agency’s plans.

Chan has to navigate a delicate path between raising alarm about a virus that in most cases causes little more than a fever and a cough, and underestimating a bug that could kill millions. Moving to the top of WHO’s six-step pandemic scale may spur some countries to restrict travel, ban public events and adopt other measures that aren’t needed for mild flu, worsening the deepest economic slump since the Great Depression.

“The formalization of an influenza pandemic does have cascading consequences,” said Michael Leavitt, former U.S. health and human services secretary. “The decision ought not to be taken lightly,” Leavitt said in an interview. “The system of evaluating and triggering different levels of alert is still being refined at the WHO.”

The Geneva-based agency, sometime in the next 10 days, will declare the first flu pandemic in 41 years, said the people, who spoke on condition of anonymity because the WHO’s deliberations are private. WHO is using the time before the announcement to help member states prepare.

“We held a series of consultations with public health officials and academics around the world to understand their concerns and get their advice about moving to level 6,” said Dick Thompson, a WHO spokesman in Geneva. “We are not at phase 6. We’re just exploring the issues associated with announcing a pandemic.”

‘Wake-Up Call’

Following yesterday’s discussion, the WHO is considering a three-point scale to denote different levels of severity once phase 6 has been declared, Keiji Fukuda, the agency’s assistant director-general of health security and environment, said on a conference call with reporters today. The experts said that besides assessing severity, the agency should offer tailored guidance to countries on how to respond to a pandemic, he said.

“WHO over the past few years has taught the public that a pandemic is a very dangerous thing,” said Peter Sandman, a New Jersey risk-communication consultant whose client list includes the U.S. Department of Homeland Security and the WHO. “If you declare a disaster every time something small happens, then eventually declaring a disaster isn’t a wake-up call.”

As far as scientists are concerned, a flu pandemic isn’t defined by its severity. The key criteria is geographic. The WHO’s guidelines say a pandemic is imminent when a new virus causes outbreaks “in at least two countries in one WHO region” and it’s in progress when it’s widespread in “at least one other country in another WHO region.” The new H1N1 flu strain, discovered in April, has turned up in 64 countries as far removed as Japan, Iceland and New Zealand.

Surprise Virus

“Much of our preparation for a pandemic was done in anticipation of a more lethal virus,” said Alan Kendal, who founded the U.S. Centers for Disease Control and Prevention’s flu branch and investigated the 1976 swine flu outbreak at Fort Dix, New Jersey. “This is taking us by surprise in that it doesn’t appear so lethal.”

The virus, a new strain that’s evolved in pigs, humans and birds, has sickened 17,410 people and killed 115 worldwide. The WHO estimates seasonal flu causes up to 500,000 deaths a year. The H5N1 bird flu virus, which isn’t easily transmitted among people, has killed 61 percent of the 432 people known to have been infected since 2003.

“In a macabre way of course, if it was really severe then a lot of decisions would be a lot easier,” Fukuda said in a May 11 interview.

Vaccine Dilemma

A move to phase 6 may trigger emergency plans around the world, the U.K.’s Department of Health said last month. Drugmakers may switch from making a seasonal flu vaccine to a pandemic one, which could leave parts of the globe without enough stocks to counter the winter flu, the department said in a May 18 statement.

GlaxoSmithKline Plc has agreements with some governments to supply a pandemic vaccine as part of national preparedness plans that would “kick in” when a pandemic is declared, said David Outhwaite, a spokesman for the London-based drugmaker.

“If you apply the current definition of phase 6 mechanically to the current global epidemiological situation, it’s difficult for WHO not to raise the alert,” said Shigeru Omi, a professor of public health at Japan’s Jichi Medical University and former WHO director for the Western Pacific. “If you announce that we are at phase 6 without any qualification, it gives a wrong impression that there are any many people dying every day. That’s a challenge.”

‘Very Scared’

WHO was asked by health ministers from China, South Korea, Japan and the 10-country Association of Southeast Asian Nations last month to consider disease severity among broader pandemic determinants. The word pandemic alone may cause people to panic, disrupting businesses and economies, said Kamnuan Ungchoosak, a Thai health ministry official.

“People don’t want to worsen what’s already a bad economic situation,” said Alan Hampson, a Melbourne-based virologist who helped draft the WHO’s first pandemic response plan in 1999 and advises Australia on preparedness.

Nature magazine, in a May 6 editorial entitled “between a virus and a hard place,” said the biggest danger posed by a flu pandemic is complacency, not overreaction.

“We have lived for five long years under the threat of a pandemic caused by the lethal H5N1 avian influenza virus,” Chan told global health leaders meeting in Geneva last month. “This has left our world better prepared, but also very scared.”