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Source: http://www.washingtonpost.com/wp-dyn...l?hpid=topnews
New Virus Spurs Experts to Rethink Definition of Pandemic
By David Brown
Washington Post Staff Writer
Sunday, May 31, 2009
Influenza experts are acknowledging that they were almost completely surprised by the way the current swine flu outbreak unfolded, so much so it is forcing the world to rethink what a pandemic is and what pandemic preparedness means.
Virtually every assumption made since planning for a pandemic began in earnest after the deadly "bird flu" outbreak of 2004 in Southeast Asia has been contradicted by the six-week history of swine-origin influenza A (H1N1).
Although they acknowledged there might be alternative scenarios, nearly every expert assumed that the next pandemic strain would jump from birds to human beings someplace in Asia. They also assumed that, like the H5N1 bird flu virus, which is lethal in 60 percent of people who catch it, the new strain would be recognized immediately and would have to be fought with drastic measures.
Instead, the virus emerged in North America, appears to have come from pigs, had spread widely by the time it was noticed, and kills less than 1 percent of the people it infects.
The world expected a fastball pitcher throwing smoke. Instead, it got a junk-baller who is throwing everyone off balance.
"Everyone was thinking about H5N1 and the possibility that we would be in for partial global population collapse," said David S. Fedson, a physician, influenza expert and former drug company executive who has written extensively on pandemic planning. "We never addressed severity, because we knew it would be severe. And now we have this funny virus coming out of pigs."
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The consequence is that, despite five years and hundreds of millions of dollars spent on getting ready, the world is oddly unprepared for the incipient pandemic of H1N1 swine flu it now confronts. As of Friday, there had been 15,510 confirmed cases and 99 deaths in 53 countries.
In the United States, plans to "limit non-essential passenger travel in affected areas" were never invoked, and an aggressive school-closing policy was quickly revised when it became clear that the virus did not travel like wildfire, and in all but a few cases caused only mild illness.
In Europe, many countries are using a public health strategy that is likely to miss many of the new flu cases rather than find as many as possible -- exactly opposite the strategy typically invoked in the early stage of a pandemic.
Some experts think there has been a reluctance to document "community spread" of the swine flu virus in countries such as Britain and Spain because it would force the World Health Organization to declare Phase 6 -- a global pandemic -- and tag those nations with triggering what seems like an unnecessarily loud alarm.
The most obvious manifestation of the world's second thoughts was the WHO's announcement last Tuesday that it will convene a conference of experts by e-mail and videophone over the next two weeks to consider changing the very definition of pandemic.
The purpose is to add measurement of the disease's severity to the criteria for moving to Phase 6, which declares "that a global pandemic is under way."
Page 2 of 2
The current rules say that if a wholly new strain of flu is spreading easily from person to person in at least two different regions of the world, then it is a pandemic. With that happening in North America and almost certainly in Europe, too, Phase 6 has already been reached in all but name. While acknowledging that Phase 6 is defined unambiguously, WHO officials say quite clearly they do not want to go there anytime soon.
"If you go and declare Phase 6 without very clear evidence that there is a sort of change in the global situation, it can lead to extra work for countries without much gain," Keiji Fukuda, the WHO's assistant director-general, said last week.
Equally important, he said, it could lead to panic and "cynicism that something is being declared which is not usefully producing something in terms of public health benefit."
Sandra Mounier-Jack, a health policy expert at the London School of Hygiene and Tropical Medicine who has written extensively about pandemic planning, agrees.
"If you announce Phase 6, many governments would be puzzled what to do," she said.
The puzzlement would not end there.
"To a lot of people, that would mean the risk has increased and the danger is greater -- even though the virus is no different than a few weeks ago," she added.
In many developing countries, plans are still being written. A survey of Africa's pandemic preparedness that Mounier-Jack and her colleagues did in June 2007 found that although 35 of 53 countries had plans, they scored on average 36 percent on a measure of "aggregate completeness."
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Hitoshi Oshitani, a virologist at Tohoku University Graduate School of Medicine in Sendai, Japan, has reviewed pandemic plans of Asian countries.
"Most of them do not have a concrete plan for Phase 6," he said Friday from Geneva, where he is helping the WHO develop guidance for low-income countries.
Most plans focus on ways to contain or delay the arrival of a highly lethal virus such as the H5N1 strain, which since 2004 has infected 427 people and killed 258, nearly all of them in Asia. The strategies include isolating patients, quarantining contacts, "social distancing" rules for the general population, and messages about personal hygiene.
Oshitani said very few plans address the situation that exists in the United States, Mexico and probably many other countries: namely, wide dissemination of a virus that is truly dangerous to only a small fraction of the population.
"We are not assuming such a kind of pandemic," he said. "A mild pandemic but very severe for certain people -- this kind of scenario was not included in most of the pandemic plans."
In that situation, the priority is to identify the people at highest risk -- pregnant women, AIDS patients and people with underlying medical conditions -- and try to protect them, ideally with a vaccine or antiviral medications.
That nearly all the swine flu vaccine and supplies of Tamiflu to be made in the next year will be bought by rich countries (or nationalized by the countries where they are made if the situation becomes dire) may also explain some of the reluctance to declare Phase 6 now, Fedson thinks.
"If you do that, it may increase the pressure on WHO to deliver on supplies of vaccines and antivirals, which it already knows will be very difficult to do," he said.
But perhaps the biggest reason is that the WHO wants to have one louder alarm at the ready should swine flu turn into a more dangerous virus over the next year. Even if that does not happen, the H1N1 strain may turn out to be more dangerous in certain places and populations than it appears to be now.
The WHO wants to be sure the world is listening -- and will hear something it cannot easily dismiss -- if it needs to sound that siren.
New Virus Spurs Experts to Rethink Definition of Pandemic
By David Brown
Washington Post Staff Writer
Sunday, May 31, 2009
Influenza experts are acknowledging that they were almost completely surprised by the way the current swine flu outbreak unfolded, so much so it is forcing the world to rethink what a pandemic is and what pandemic preparedness means.
Virtually every assumption made since planning for a pandemic began in earnest after the deadly "bird flu" outbreak of 2004 in Southeast Asia has been contradicted by the six-week history of swine-origin influenza A (H1N1).
Although they acknowledged there might be alternative scenarios, nearly every expert assumed that the next pandemic strain would jump from birds to human beings someplace in Asia. They also assumed that, like the H5N1 bird flu virus, which is lethal in 60 percent of people who catch it, the new strain would be recognized immediately and would have to be fought with drastic measures.
Instead, the virus emerged in North America, appears to have come from pigs, had spread widely by the time it was noticed, and kills less than 1 percent of the people it infects.
The world expected a fastball pitcher throwing smoke. Instead, it got a junk-baller who is throwing everyone off balance.
"Everyone was thinking about H5N1 and the possibility that we would be in for partial global population collapse," said David S. Fedson, a physician, influenza expert and former drug company executive who has written extensively on pandemic planning. "We never addressed severity, because we knew it would be severe. And now we have this funny virus coming out of pigs."
ad_icon
The consequence is that, despite five years and hundreds of millions of dollars spent on getting ready, the world is oddly unprepared for the incipient pandemic of H1N1 swine flu it now confronts. As of Friday, there had been 15,510 confirmed cases and 99 deaths in 53 countries.
In the United States, plans to "limit non-essential passenger travel in affected areas" were never invoked, and an aggressive school-closing policy was quickly revised when it became clear that the virus did not travel like wildfire, and in all but a few cases caused only mild illness.
In Europe, many countries are using a public health strategy that is likely to miss many of the new flu cases rather than find as many as possible -- exactly opposite the strategy typically invoked in the early stage of a pandemic.
Some experts think there has been a reluctance to document "community spread" of the swine flu virus in countries such as Britain and Spain because it would force the World Health Organization to declare Phase 6 -- a global pandemic -- and tag those nations with triggering what seems like an unnecessarily loud alarm.
The most obvious manifestation of the world's second thoughts was the WHO's announcement last Tuesday that it will convene a conference of experts by e-mail and videophone over the next two weeks to consider changing the very definition of pandemic.
The purpose is to add measurement of the disease's severity to the criteria for moving to Phase 6, which declares "that a global pandemic is under way."
Page 2 of 2
The current rules say that if a wholly new strain of flu is spreading easily from person to person in at least two different regions of the world, then it is a pandemic. With that happening in North America and almost certainly in Europe, too, Phase 6 has already been reached in all but name. While acknowledging that Phase 6 is defined unambiguously, WHO officials say quite clearly they do not want to go there anytime soon.
"If you go and declare Phase 6 without very clear evidence that there is a sort of change in the global situation, it can lead to extra work for countries without much gain," Keiji Fukuda, the WHO's assistant director-general, said last week.
Equally important, he said, it could lead to panic and "cynicism that something is being declared which is not usefully producing something in terms of public health benefit."
Sandra Mounier-Jack, a health policy expert at the London School of Hygiene and Tropical Medicine who has written extensively about pandemic planning, agrees.
"If you announce Phase 6, many governments would be puzzled what to do," she said.
The puzzlement would not end there.
"To a lot of people, that would mean the risk has increased and the danger is greater -- even though the virus is no different than a few weeks ago," she added.
In many developing countries, plans are still being written. A survey of Africa's pandemic preparedness that Mounier-Jack and her colleagues did in June 2007 found that although 35 of 53 countries had plans, they scored on average 36 percent on a measure of "aggregate completeness."
ad_icon
Hitoshi Oshitani, a virologist at Tohoku University Graduate School of Medicine in Sendai, Japan, has reviewed pandemic plans of Asian countries.
"Most of them do not have a concrete plan for Phase 6," he said Friday from Geneva, where he is helping the WHO develop guidance for low-income countries.
Most plans focus on ways to contain or delay the arrival of a highly lethal virus such as the H5N1 strain, which since 2004 has infected 427 people and killed 258, nearly all of them in Asia. The strategies include isolating patients, quarantining contacts, "social distancing" rules for the general population, and messages about personal hygiene.
Oshitani said very few plans address the situation that exists in the United States, Mexico and probably many other countries: namely, wide dissemination of a virus that is truly dangerous to only a small fraction of the population.
"We are not assuming such a kind of pandemic," he said. "A mild pandemic but very severe for certain people -- this kind of scenario was not included in most of the pandemic plans."
In that situation, the priority is to identify the people at highest risk -- pregnant women, AIDS patients and people with underlying medical conditions -- and try to protect them, ideally with a vaccine or antiviral medications.
That nearly all the swine flu vaccine and supplies of Tamiflu to be made in the next year will be bought by rich countries (or nationalized by the countries where they are made if the situation becomes dire) may also explain some of the reluctance to declare Phase 6 now, Fedson thinks.
"If you do that, it may increase the pressure on WHO to deliver on supplies of vaccines and antivirals, which it already knows will be very difficult to do," he said.
But perhaps the biggest reason is that the WHO wants to have one louder alarm at the ready should swine flu turn into a more dangerous virus over the next year. Even if that does not happen, the H1N1 strain may turn out to be more dangerous in certain places and populations than it appears to be now.
The WHO wants to be sure the world is listening -- and will hear something it cannot easily dismiss -- if it needs to sound that siren.