My complete response to Helen Branswell’s email inquiry is also on this website.
TORONTO — The World Health Organization, under pressure from member states not to declare the swine flu outbreak a pandemic, said Friday it will rework the criteria by which a pandemic is called.
A number of countries have been pressing the global health agency not to move to Phase 6 - a pandemic – from the current Phase 5. They have argued that while the virus is clearly spreading to many parts of the world, the mild illness it is causing in the vast majority of cases doesn’t merit pandemic status.
The WHO’s acting assistant director-general said a number of countries attending this week’s World Health Assembly in Geneva asked for more flexibility in the pandemic alert scale than the tool currently provides – and the WHO agreed to rethink the criteria.
“Rigidly adhering to something which is not proving to be useful in fact would not be very helpful to anybody,” Dr. Keiji Fukuda said during a media teleconference from Geneva following the end of the assembly, the annual meeting of the WHO’s governing counsel.
“What has become clear is that it’s not just the spread of the virus which is considered important by countries who really have to act upon the phase changes. It’s really the impact on the populations.”
The existing scale, recently approved after three years of consultations and drafting, was drawn up while the WHO and the influenza experts who advise it were nervously watching the H5N1 avian flu virus. H5N1 has killed 60 per cent of the people it has been known to infect.
Under the scale’s criteria, the WHO would declare a pandemic if a new virus was found to be spreading in the community in countries in two WHO regions. That condition seemed to be on the verge of being met, with the virus spreading rapidly in Japan.
As of Friday 42 countries had confirmed more than 11,000 cases of the infection, with 86 deaths. Canada has confirmed 805 cases and one death.
A leading U.S. public health official, who earlier this week said he believes the world is already in a pandemic, said the decision is about “semantics.”
“They are entitled to create whatever criteria they wish to define their terms,” said Dr. Jeff Duchin, head of the communicable disease division of Seattle and King County Public Health in Seattle, Wa.
“I think Bob Dylan had a point when he said you don’t need a weatherman to know which way the wind blows.”
However, a professor of international law at Indiana University said the WHO had little choice but to agree to change the pandemic phase levels.
Further, David Fidler said the decision was a “politically and epidemiologically prudent call, even if some critics will characterize it as caving into political pressure.”
“Countries, out of fear or for ulterior motives, may use the declaration of a pandemic to take actions that are unnecessary for this milder virus and would cause political, economic, or human rights damage that would create no public health benefit,” said Fidler, who is director of the Center on American and Global Security.
“I think that is the message the countries were sending WHO in counselling the Director General” – Dr. Margaret Chan – “not to raise the level to Phase 6.”
But a leading risk communications expert who has worked with the WHO and other public health organizations in the past criticized the decision.
“I think it is unnecessary and even foolish for WHO to change its definition of ‘pandemic’ in order to avoid frightening people with the word,” said Peter Sandman, of Princeton, N.J.
“The concern that people will over-react to a pandemic declaration and demand unwise, futile, and costly precautions (like border closings) is overwrought. It is what I call ‘panic panic’ – unreasoning fear on the part of governments that their people won’t be able to cope.”
Sandman did, however, support the notion of adding additional phases to the alert scale to reflect pandemics of escalating levels of severity. “It would be better to invent new phases for worse pandemics than to redefine ‘pandemic’ itself.”
Fukuda couldn’t say Friday how soon the new criteria will be drawn up, by what process they’ll be devised or what they’ll entail.
And in an interview, he hinted it may not be an easy task.
“It is far beyond just wordsmithing a couple of criteria in or something,” Fukuda said. “And so I think that requires a fair amount of thinking through.”
He suggested severity of disease caused by a new virus will likely be worked back into the equation, though it won’t be the only new factor. Severity had been in an earlier version of the pandemic phase scale.
“But I can tell you that what we are looking for and what we will be looking for is … events which signify a really substantial increase in risk of harm to people,” Fukuda said. “I think this is the sense of what Phase 6 is meant to convey. And this is what we will be focusing on.”
Previously the WHO had said weighing severity as part of the decision of whether to call a pandemic was problematic. History shows pandemics don’t play out the same way in each location, and a virus that starts out inflicting only mild disease could evolve to become a more dangerous foe.
Countries from the Association of Southeast Asian Nations had called on the WHO at a recent meeting not to declare the swine flu outbreak a pandemic. And at this week’s World Health Assembly, in discussions Fukuda described as “intense,” a number of countries argued that calling a pandemic would instill a level of fear in the public that isn’t warranted by the illness caused by this virus.
Fukuda suggested it is “entirely reasonable” to revisit when to declare an outbreak a pandemic, given the current circumstances.
“Over and over again we rethink things through. And as more information comes in, we change, we adapt to those realities and those things that we think are going to be more helpful.”
But he admitted the situation is “fraught with difficulties” and could hurt the credibility of the WHO, depending on how it is characterized.
An infectious diseases expert who earlier this week warned the WHO’s reputation could be battered by a debate over whether to call swine flu a pandemic welcomed the agency’s decision to revisit the criteria for declaring a pandemic.
Dr. Michael Osterholm said it doesn’t really matter what the WHO calls the swine flu outbreak, as long as countries monitor it closely and report openly and quickly about what it is doing within their borders.
“I think all we want to do is motivate people to provide the most clear and compelling picture of what’s happening in our communities around the world,” said Osterholm, director of the University of Minnesota’s Center for Infectious Diseases Research and Policy.
“I don’t want to see a nomenclature debate become the reason why people do or don’t try to understand what’s happening with the disease.”
Copyright © 2009 by Canadian Press