The World Health Organization (WHO) is not the world's health department or the world's doctor. It is an intergovernmental agency that is part of the United Nations (UN). The UN, despite what hard right wingnuts might think, is not a world government. The international system is technically anarchic, meaning that there is no governing body above nationally sovereign states. For the most part, WHO has no powers beyond those granted it by its member nations (for more background, see our five part series over at the old site here, here, here, here, here). It is only within the last few years that WHO has even begun to bring its approach partially into line with the global reality that infectious diseases don't care about national borders. In 2007 new International Health Regulations came into force for the first time that impose responsibilities on member states to report diseases of international significance to WHO and allow WHO to issue travel advisories. Those advisories are just that: advisory.
More importantly, WHO can do nothing about states that decide to close borders or ban travel despite WHO's own advice that such measures are unwarranted. And when they do, WHO cannot prevent them from using WHO as an excuse, whether the action is ulterior motive or mistaken or differing judgment. On the other hand, governments who for whatever reason do not wish to acknowledge WHO's judgment, are often keen that WHO refrain from announcing to the world something that would be inconvenient for them. Which brings us to the tangle around whether WHO should admit the obvious: that by their own criteria we are at phase 6, i.e., a pandemic with a novel influenza virus is underway.
While I have sympathy for the delicate situation WHO finds itself in with respect to some of its influential member states (the UK, Japan, China to name a few), it is compounding the problem by trying to have it both ways. Finding its system for declaring pandemic phases not well suited to the situation, it is also finding it hard to admit it is changing the basis:
On 29 April, WHO raised the pandemic threat level from 4 to 5, citing sustained community transmission in the U.S. and Mexico. At the same time, WHO said phase 6 was “imminent” and would be declared if the same type of spread appeared in a second region of the world. But at a press conference today, Keiji Fukuda, WHO's assistant director-general, said that representatives from several countries who attended the World Health Assembly in Geneva this week criticized the current phasing system, which relies solely on geographic spread without regard to severity of disease.
Fukuda said WHO agreed with the countries that the phase system needs to more accurately reflect the impact the virus is having on populations. Fukuda also said WHO might bump up the alert to phase 6 if the virus started to spread significantly in the Southern Hemisphere, including South America and Africa, even without causing severe disease.
To clarify this confusing potential revision of the definition of phase 6, ScienceInsider asked whether WHO would declare a pandemic right now if the virus were the much deadlier H5N1 that causes avian influenza. “Even if it were H5N1, we would still be looking for clear evidence of widespread community outbreaks going on in countries in multiple regions,” said Fukuda. “This is still a situation that we have not seen yet.” (Jon Cohen, ScienceInsider)
It is both fruitless and pointless for WHO to deny it is responding to political pressure. The main question is whether that response is a reasonable and prudent one, given the facts of the situation. I think a good argument can be made that it is, and Fukuda made this case to Cohen:
“What is the value of these phases?” asked Fukuda. “These kinds of tools are really there to help countries prepare themselves.” For the most part, he said, that has happened, and he stressed that WHO must remain flexible. “There is nothing like reality to tell you whether something is working or not,” said Fukuda.
This position is also at taken by the Director of the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota, Dr. Michael Osterholm. As quoted by Canadian Press's Helen Branswell we think he has it exactly right:
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." (Helen Branswell, Canadian Press)
Reporting accurately what's happening within its borders is what the UK Labor government is not doing. They seem to be in an active state of denial, perhaps a defense against a failed (and stupid) policy:
Flu experts are looking very closely at Britain — and some have decided that the U.K.'s swine flu-fighting tactics are seriously off the mark and may be hiding a much larger outbreak.
Since Britain has the most confirmed swine flu cases in Europe, how the outbreak develops here will have a significant influence on whether the World Health Organization decides to raise its flu alert to the highest level — a pandemic, or global epidemic.
British authorities have relied on an aggressive strategy to try to snuff out the virus before it spreads, blanketing suspect cases and anyone connected to them with the antiviral medication Tamiflu. (Maria Cheng, AP)
Officially the UK now has 117 cases. "Meaningless" says one of the country's leading flu scientists:
Thirty thousand people in Britain are likely to have been already infected by swine flu, one of the country's leading authorities has told The Independent on Sunday. This would mean that the virus is 300 times more widespread than the Health Protection Agency (HPA) admits.
The startling estimate by top virologist Professor John Oxford comes as leading scientists are warning that the agency's announcements on the spread of the disease are "meaningless" and hiding its true extent. And it tallies with official estimates made in the United States. (Geoffrey Lean, The Independent [hat tip crof's blog])
If the total is truly around 30,000, most of them are probably are probably undiagnosed mild or inapparent cases. But they are still there, and the idea that the infection can be "snuffed out" with a Tamiflu blanket is ridiculous and a waste of time, effort, money and medication. If the ultimate goal of whatever WHO does with its system is for its member states in Osterholm's apt phrasing, to "motivate people to provide the most clear and compelling picture of what's happening in our communities around the world," then the UK and probably other governments have not met the mark.
Whatever system WHO adopts, it should encourage a clear-eyed view and not the kind of intellectual dishonesty we see in the UK and likely a number of other European countries.
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Fukuda said WHO agreed with the countries that the phase system needs to more accurately reflect the impact the virus is having on populations.
From his Doctors without Borders experience in India, among others, Keiji Fukuda is well aware of the psychological harm a declaration of a pandemic can have on some Cultural collectivities that had suffered in previous pandemics (from those of smallpox and others among the First Nations of the American Hemisphere or among Indians of India in 1918 for example).
It is quite easy for someone who has a meal a day, enough water and access to informations and a doctor to acknowlege a true technical pandemic, but what about those who are barely surviving, stress to the max, and experience epidemics on an on, loose child and families and are historically traumatised by epidemics and pandemics.
If this pandemic is "mild" as Academics state wouldn't it be arrogant that to be technically relevant to declare a World Wide Pandemic for the sake of Technical accuracy, thus disregarding the damage that such presumptuous and Non-Humanitarian Statement would cause?
Are there still a lot of academic that do not care about the effects of their statements among populations.
The first Medical rule is Do not Harm isn't it?
May Technical Aristocrat in their Ivory Towers learns to Care about population more than their technical accuracy.
Because if they just want to be technically accurate it means that Science tries to overrule Cultures and Populations.
The Backlash could bring Science Authority back to the Middle Age.
Just be Humanitarian and first do no harm.
Snowy Owl
Snowy Owl
Does that mean the pandemics of '57 and '68 are henceforth to be called "The Localised Infectious Disease Outbreaks Formerly Known as Pandemics"?
I see nothing non-humanitarian in officially declaring a global health event that will cause 4 million excess deaths over the next 12 months if we are lucky.
We entered this event with a pandemic alert phase system which does not explicitly address severity, but assumptions regarding severity are implied. It seems to me both fruitless and pointless to deny that the system was designed with a more virulent agent in mind. Under the circumstances, what choice does WHO have but to recalibrate on the fly? If they go to phase 6 with this thing, and it swaps some genes around with you-know-who, and comes roaring out with a CFR of, say, something like five percent, won't WHO end up needing to find a way to express the increase in the threat level? What are they going to do, tag on a "phase 7"?
so how is UK's policy and why they have failed or are stupid? How do the experts come up with the 30K number?
I think they should tack on more levels myself. The definition of the highest level (phase 6) is too low.
Isn't everyone underreporting? Look at all the countries declaring one case over the past month-who are they kidding?
You certainly are one of the most respected sources for information on flu and I mean no disrespect. I live in New York and I am very anxious too. I think it is artificial for experts to look at the UK as the only example of data suppression and poor surveillance. I have read numerous accounts of sick people trying to get tested here in the US (including sick healthcare workers) and they are being told that the labs are overwhelmed while at the same time the occurence rates remain unchanged for days at a time. I realize you are not guilty of this but other sources are. It seems to be a governmental imperative to get under the WHO criteria to keep tourism and economies from getting any worse during this worldwide recession, and maybe to prevent panic as well. I respect the government's need to keep things under control and do not question their judgment too much, just think everyone is doin' it and probably for good reason (reasons beyond me but probably valid).
For fellow obsessives who like details, here are links to the WHO pandemic phase definitions from 1999, 2005, and April 2009:
1. This WHO document includes the pandemic phases as revised in 2005, at http://tinyurl.com/bdyme . The 2005 revision includes a severity factor with regard to Phases 3, 4, and 5 (search âthe distinction between phase 3, phase 4 and phase 5â to find the relevant footnote).
2. This document, Comparison of the pandemic phases published by WHO in 1999 and in 2005, at http://tinyurl.com/o6jpo2 , includes a side by side comparison of the 1999 WHO pandemic phases and the revised 2005 WHO pandemic phases.
3. And this document contains the April 2009 WHO revised pandemic phases, at http://tinyurl.com/dlsshw . It also includes a description of the revision process, and a list of participants in the process.
"We entered this event with a pandemic alert phase system which does not explicitly address severity, but assumptions regarding severity are implied. It seems to me both fruitless and pointless to deny that the system was designed with a more virulent agent in mind."
I beg to differ. The WHO has been vehemently repeating that the worst case scenario for a future pandemic is a CFR of 2.5%; for this novel flu virus the majority of estimates I have seen place the CFR in the 0.7% - 1.5% range, exactly as the WHO itself predicted for the future flu pandemic.
The scale change reflects the failure of the WHO and world state leaders to professionally prepare and explain the pandemic risk to the public, so that they now find it more convenient to pretend the scale is faulty.
To repeat my question - do we agree then that there was only one flu pandemic in the 20th century and that history and medicine textbooks have to be rewritten only because the WHO is afraid to follow its own guidelines?
Until we know more about how many subclinical or asymptomatic cases there are, I don't think we really have anything on CFR that really deserves to be call an "estimate". There is plenty of speculation, but that's not quite the same thing. It's been speculated that with this virus we can expect a CFR comparable to typical seasonal flu: somewhere around 0.1%. You can certainly obtain higher "estimates" by simply dividing the number of deaths by the number of confirmed cases, but as revere has pointed out, such an approach is problematic to say the least.
I also don't see much coming from WHO that really deserves to be called "vehement". History only provides one example of a severe pandemic, and that one happens to have a CFR estimated at 2.5% (and even that "estimate" borders on speculation). Where predicting and responding to an epidemiological event featuring a novel influenza is concerned, success and failure is going to be measured in relative terms, but if you wanted to guarantee failure, rigidly clinging to obsolete ideas would be a good place to start. Influenza is capable of quickly adapting to new situations; if we can't do the same, we're sunk.
The World Health Organization is the 'Wizard of Oz'.
That is all they will ever be...a non-issue of no consequence.
All that's necessary for WHO to be of consequence is for decision-making entities (vaccine manufacturers and government agencies) as well as media, to treat it as being of consequence. Since they do, it is. Besides that, it's the closest thing we have to an effective global surveillance network.
revere, nothing to add here. You are right on every point. I despair, as a UK citizen.
Last time I checked WHO still listed three pandemic events in the 20th century, not one, and those in 1957 and 1968 seem to be close in CFR to the present one. I'm sorry but I do not accept the claims that the pandemic alert scale was created with a more serious event in mind. The WHO has been sending signals for a long time now that if we're lucky we're going to have a repeat of the mild mid-century pandemics, and if we're not the worst that can happen is another 1918. Incidentally, if you look at other potential pandemic candidates such as H5N1 with is CFR of 60%-80%, even this prediction seems problematic.
There is no justification for treating this virus as non-pandemic, at least from the epidemiological perspective. Politically - that's a different story.
Lets get real.
We are experiencing an influenza pandemic for the first time in 31 years and while this particular strain appears to be "benign" it remains virulent.
Virtually all of humanity is susceptible to this strain. It is traveling across the globe. Is it not likely that at some point it will encounter a host co-infected with H5N1? When this happens, and it is likely to do so many times, what will be the outcome?
If the A/H1N1 Mexican Flu exchanges genetic material with the H5N1 bird flu within a co-inflected host cell the result could be catastrophic.
What's more there is nothing we can do about this. We must simply sit and watch for we have no control over these events.
Grattan Woodson, MD
Oh, and one more thing - if this virus is so mild, why did the WHO decide to release its entire prepandemic antiviral stockpile to contain it?
Also, even assuming the speculative CFR of 0.1%, with no herd immunity to the novel virus and 30% attack rate predicted by WHO officials that will give you 2 billion sick and 2 million dead. That's substantially more than seasonal flu death toll.
And yes, you are absolutely right, any CFR is speculative atm. What is not speculative is the age group that is targeted by the new virus, which is markedly different from seasonal flu. Moreover, the current CFR has been obtained by generous use of antivirals, which are not going to be there for every one of the 2 billion affected people. And finally, so far we are seeing the virus in action in countries with more (the US) or less (Mexico) decent health sector. When it gets to Africa and Asia, a different picture is likely to emerge.
Early on in this outbreak, a number of people.. including some who posted on this blog... tried to do some curve fitting to the data.
Any update ? We seem to have gone from a rapidly accelerating phase (doubling every few days) to something much less dramatic.
Grattan,
Of course we all know that we are amidst a pandemic, at least by the book.
WHO neglected a very important part of its unicersal Mission and is paying the price now, that is a mass education program.
They know how to do this, they did it in Africa with aids and in many countries with dengue and in India with Chickungunya.
Now is the time for rich countries to invest in educating the mass in discerning what pandemics are, what virulence is, what Preparedness is, how to do it, like getting your boof translated.
At the same time WHO has to adapted to Historical and Culturals sensibilities with a totally new structure of levels of warning.
Meanwhile, govs and powers must push hard for better monitering in this context, better governemental preparedness and mostly a vast campaing of sensibilisation.
We can do it, the timing is right, and all Authorative elements are in the right position.
Snowy Owl
If the WHO wants to try getting into the severity rating game, with all its inherent difficulties, inaccuracies and instabilities... well, I wish them the best of luck. Doing epidemiology without reliable numbers on a virus capable of evolving as quickly as an influenza A virus doesn't sound like a walk in the park to me.
But severity scale or no, a pandemic is just a worldwide epidemic. It's all about spread -and nothing else. There's no reason these two measures (the definition of a pandemic, and whatever severity rating scale they come up with) should be tied together. They should be separate measures used in tandem to present a (hopefully) more complete picture of the nature of a given pandemic.
Meanwhile, let's get ourselves in line with reality and start calling this what it is: a pandemic.
If this were the spring of 1918 rather than the spring of 2009, how would the WHO have responded...
probably that all signs indicated a mild pandemic.
They are predicting a mild pandemic with little data to support their conclusion.
Influenza is unpredictable...we shouldn't be predicting anything...instead warning all persons to prepare for what might be a very tough winter.
If that tough winter comes, there are going to be a lot of angry parents...with good reason.
I think the first thing we need is real data. We are clearly at phase 6 but without a real understanding of the extent of transmission (we think large, fast, ?) or its rates of anything. We are guessing -- the WHO, the CDC, everyone. What we need to do is not redefine the phase numbers -- we need to quickly revise the sampling populations and the testing. That alone in my opinion will give us the needed information to make functional decisions. We hope its this or that but we simply don't know. We have some good GUESSES! Instead of the poor sampling that seems to be done in numerous countries aka trying to poorly sample a large population, or differentially sampling only the severe parts of large populations, maybe the WHO should recommend taking one hospital (or other community structure -- school for example) and sample every member. This is admittedly a snapshot but at least we could potentially get an idea of real extent, transmission, and mild vs severity rates.
It seems to me that the phases issue might be dealt with is to have two scales. The the current one focusing on spread and a second focusing on severity. This would allow governments and the public to know how wide spread the disease is and how serious it is for an individual getting the disease.
Public health agencies then have a preset framework for different types of severity since I presume as a member of the general public with no medical experience the public health response is different a flu with a low CFR or hospitalization rate is different than one with a high CFR or hospitalization rate. It would also allow governments to focus on what they deem most important for the public to know.
We already are using an informal second component when the word mild is used. This would give a standardized language for everybody to use that would be less confusing and easier to explain then just tossing an undefined mild before the word pandemic.
I think the first thing we need is real data. We are clearly at phase 6 but without a real understanding of the extent of transmission (we think large, fast, ?) or its rates of anything. We are guessing -- the WHO, the CDC, everyone. What we need to do is not redefine the phase numbers -- we need to quickly revise the sampling populations and the testing. That alone in my opinion will give us the needed information to make functional decisions. We hope its this or that but we simply don't know. We have some good GUESSES! Instead of the poor sampling that seems to be done in numerous countries aka trying to poorly sample a large population, or differentially sampling only the severe parts of large populations, maybe the WHO should recommend taking one hospital (or other community structure -- school for example) and sample every member. This is admittedly a snapshot but at least we could potentially get an idea of real extent, transmission, and mild vs severity rates.
I agree with the findings in this article. The WHO is also late in reporting data. I get my swine flu info each day from FluCount.org and it's usually not until a few days later that the WHO gives the same figures. But people, for some reason, think the WHO is the world's doctor.
Yes we are in the midst of a pandemic and no we can not predict how it will turn out.
Yes the pandemic Mexican Flu A/H1N1 is likely to encounter both human adapted flu strains and H5N1. When this happens there is a good chance that these viruses will exchange genetic material. The outcome of this exchange is unknown but not likely to be good from the human perspective.
The important thing for all is to decided for yourself if the possibilities presented above represent a threat or not and if they do take action now to protect your family and friends.
OTOH, if you have your doubts then stay tuned. The show is just getting going and will be quite revetting before the TV goes off.
So, it is your choice. You can take the time we have left to prepare or become a deer in the pandemic headlights.
GW
As a non-scientist. non-health professional member of the general public, it seems to me that creating a severity scale would be an enormous mistake. Folks like me are busy and occupied. Unless we have an interest in the topic, we don't have a lot of time to spend investigating the flu and how it's described. What folks want to know is if they and their loved ones are in danger.
If the WHO creates a severity scale, say 1-6 like the pandemic scale, do you really think folks are going to change their behaviors if the level is 1-4? Unlikely. The general public would pay even less attention than they're paying now with no scale. If the level was raised to 5 it would garner media coverage and would get some people's attention, but again, if they didn't think they or their loved ones were in danger, they won't give it more than a few minutes consideration, perhaps seeing if kids were sick at school or restocking items in their larder or picking up some Pedialyte "Just In Case." The scale would have to reach 6 before the majority of folks took notice and then their reaction would be panic. You'd see everyone wearing masks, store shelves wiped clean, gas lines, and ER's overloaded with terrified snifflers and sneezers.
As well, how would the WHO scale a flu with a much higher CFR in places where endemic poverty, limited medical resources, and such make everyone who contracts the disease more vulnerable than folks in, say, Connecticut? Would the WHO announce it's at level 5 in Botswana and 3 in the states? Would each WHO region get their own level? Each country? Each state?
On top of those issues, if politics came into play (as they obviously have now) would countries intentionally misrepresent their CFRs so their severity level remained low and travel and commerce remained high -- at grave risk to all?
Seems to me a severity scale would be a nightmare!
At least that's this writer's thoughts...
As well, how would the WHO scale a flu with a much higher CFR in Africa where endemic poverty, limited resources, and such make everyone who contracts the disease more vulnerable than folks in Connecticut? Would they say it's a 6 in Botswana and a 3 in the states?
A severity scale would turn a public education headache into a horrific nightmare. Stick with calling it a pandemic (and they should, now) and shy away from creating a severity scale.
One writer's thoughts...
Dr. Woodson
Your post at 10:29 is an wonderfully concise piece of writing!!
Thanks
44 at one single school in the UK. There is something that does not ring true about the numbers... it seems highly infectious but the official data shows a fall off in the rate of growth.
What is happening?
Official data in many areas where spread is generalized now only counting severe or hospitalized cases. (Reporting requirments for health care providers have changed correspondingly.)
Why? They don't have capacity or (given the apparent mildness of IA (H1N1)) justifiable reason to allocate resources to test, verify and count more than that.
So charting the growth rate will be difficult.
Much work went into calibrating US pandemic response to both the geographical spread of the novel virus and the severity of the particular virus.
That relationship between progress, virulence and proportionate response was never perfect, but it was given quite a bit of thought and work before it was published in 2007.
Of course now, at least as far as the general public is concerned, both the governmental Response Stage and the Pandemic Severity Index belong on milk cartons under a label: Missing - Have You Seen?
As for WHO's Remedial Pandemic Math issue, I keep thinking of a quote from Abraham Lincoln:
"How many legs does a dog have if you call the tail a leg? Four. Calling a tail a leg doesn't make it a leg."
And, I might add, vice versa.
WHO may redefine pandemic alert phases
Robert Roos News Editor
May 26, 2009 (CIDRAP News)
http://www.cidrap.umn.edu/cidrap/content/influenza/swineflu/news/may260…
Quote
In response to concerns from various governments about the possible effects of declaring a full-scale influenza pandemic, the World Health Organization (WHO) will call on outside experts to consider whether to revise the agency's definitions of pandemic alert phases, a WHO official announced today.
snip
At the WHO's annual meeting last week, several countries, concerned about potentially causing undue alarm, urged the WHO to go slow on moving to phase 6. Noting that most H1N1 cases have been mild, they argued that the pandemic phases should reflect not only the geographic extent of the disease, but also its severity.
Today Dr. Keiji Fukuda, the WHO's assistant director-general for health security and the environment, said the agency would call on scientists and public health experts to consider whether to change the phase definitions.
"What we're currently doing at WHO is trying to take a look at the interventions and see what kind of adjustments might be made to make sure the definitions really meet the situation," Fukuda said at a news teleconference. "To do this, we will be asking scientists and public health people who really have a good perspective on the issues to help us think this through."
He said he hopes this can be accomplished within the next few weeks.
Fukuda said the reasons for the WHO's decision include not only the concerns expressed at the World Health Assembly last week, but also an earlier request from southeast Asian countries at the ASEAN meeting. Officials at that meeting asked the WHO to consider whether the criteria for moving to phase 6 should be adjusted.
He commented that the alert phases were developed a tools to help governments prepare for a pandemic. The phases, he added, were fashioned "in the shadow of avian influenza H5N1," which has caused rare but often lethal human cases, unlike the novel H1N1 virus, which usually causes mild illness.
"The spread of this virus has really highlighted the fact that this is a very different situation than with H5N1," he said
snip
Echoing his comments at a May 22 news briefing, he argued that the most important issue is not the pandemic phase definitions but whether proper public health actions are being taken in response to the disease.
Reporters asked Fukuda why the WHO is so reluctant to go to phase 6, since it officially means only that the virus is spreading in more than one region and says nothing about its severity.
"I think the answer is really almost another questionâthe question of what is to be gained by going to another phase?" he replied. "When we went from phase 3 to phase 4 and from 4 to 5, there were real gains for countries by doing that, in terms of focusing attention, in terms of implementing actions, in terms of bringing in resources and really focusing everybody's attention on what had to be done."
He added that many countries are already responding appropriately to the epidemic, and that moving to phase 6 could cause unnecessary work and potentially lead to panic and cynicism.
"If we go to phase 6 without very clear evidence that there's a sort of change in the global situation, it can lead to extra work without much gain, it can lead to some level of panic, it can lead to some level of cynicism that something's being declared but is not usefully producing something of public health benefit or gain," he said.
He further observed that the pandemic phase definitions have evolved to become simpler in response to feedback that the earlier versions were too complicated. But now the WHO has found that they don't adequately capture the concerns of countries.
In response to a question, Fukuda said the move to reconsider the phase definitions doesn't necessarily mean the WHO won't declare a pandemic if the epidemiologic situation changes while those deliberations are under way.
end quote
26 May 2009 press briefing
Listen to Dr Keiji Fukuda, Assistant Director-General ai, Health Security and Environment [mp3 49Mb] at
http://www.who.int/mediacentre/multimedia/swineflupressbriefings/en/ind…
Snowy