WHO under fire over flu alert system

[pablomorgan]

he World Health Organisation is considering an overhaul of its pandemic ratings system amid growing criticism that it provoked unnecessary alarm by rapidly escalating its warnings over swine flu.

Officials at the agency?s headquarters in Geneva said they were discussing changes to the 6-point scale to make clear in the future the gravity of the threat posed by a new virus.
EDITOR?S CHOICE
US anti-terror controls delayed flu response - May-06
In depth: Swine flu - Apr-28
Slideshow: Swine flu global reaction - May-01
Table: Swine flu cases around the world - May-06

The move comes against a backdrop of intensifying attacks on the WHO which has been accused of ?crying wolf? over its decisions to raise its pandemic alert from level three to an unprecedented five. This comes amid indications it may even go to the maximum level six.

Media organisations initially seized on the upping of the alerts in frontpage headlines around the world, but as it has emerged that the death toll has stayed relatively low, so the criticism has mounted. As of this morning (Thurs) the WHO confirmed 2099 cases in 23 countries including 44 deaths.

While designed to identify and classify the spread of a new flu virus between humans around the world, the WHO?s system of pandemic alerts provides no indication of the danger of the virus.

Even if the A (H1N1) virus in Mexico proves no more lethal than a typical seasonal flu, it could still soon trigger the highest level six WHO pandemic alert once it has been identified as spreading widely between humans in different parts of the world.

Margaret Chan, the director general of the WHO, has stressed that an increase to level six is a technical change which does not mean that people around the world are at serious threat.

In an interview with the FT earlier this week Ms Chan defended the organisation?s public statements. ?I am not predicting the pandemic will blow up but if I miss it and we don?t prepare, I fail. I?d rather over-prepare than not prepare.?

But her reassurances clash with a widely-held public understanding of a pandemic as a serious infectious disease.

Only two weeks after the Mexican virus was first decoded, health officials are still struggling to understand which age groups and what overall proportion of a population are infected by the flu, and how many are at risk of dying becoming seriously ill as a result.

With such limited data, they still want to be able to alert health authorities around the world to the potential risks so they can step up their response while gathering more information.

Scientists also warn that even if outside Mexico the virus has so far proved relatively mild, there is a significant danger that it could mutate on mixing with some of the seasonal flu viruses now starting to circulate in the southern hemisphere which are widely resistant to antiviral treatments such as Tamiflu.

The ?Armageddon? scenario is that it might mix with the H5N1 bird flu virus, which is highly lethal in humans but so far has not proved efficient at being transmitted between humans.

The WHO already sparked concerns from a number of health authorities for changing its pandemic alert scale last month just after the Mexican virus was identified. This had the effect of speeding up the escalation from level 3 and was out of synch with many national pandemic plans.

Anthony Kessel from the UK?s Health Protection Agency, said the current arrangements were ?a necessary alert system? but added: ?It will be important for the WHO?s member states and advisory bodies to determine whether in the future a link with the severity of the infection is feasible, and whether it would add value to our current system.?

Copyright The Financial Times Limited 2009
http://www.ft.com/cms/s/0/e89de9ea-3b11-11de-ba91-00144feabdc0.html

 

[Vibrant62]

Re: WHO under fire over flu alert system

I am puzzled by the WHO responses to these criticisms in the media - my understanding is that the alert system was designed to trigger various levels of national alerts to ensure that systems could cope with an influx of patients in case of a pandemic outbreak, regardless of severity. These responses take time to plan for and put into place, whether at a business level or a health management level.

More importantly the Alert system is designed to hopefully allow for containment and control of a pandemic before it erupts, especially one that appears to have a potential to be severe (such as H5N1) allowing for the possibility that a pandemic could be contained and averted, or at least delayed.

What is required here is clarification and education of what the alert system is there for, and why it exists at all. To further modify the system such that alert levels are only raised after the outbreak is established and all facts are known would defeat these objects, and render the system next to useless.

 

[tropical]

Re: WHO under fire over flu alert system

#1: ...


The WHO choice is the minimum which must be done.

What is espected from these critics, that the levels must rises to 5/6 when we all starts to die as flies?

Than would be already late to alram/prepare or shield anybody.

The meaning of the pandemic risk levels is to alarm and give time for preparations.

So let it be that way.

To not mention that without the rise of the levels to 5, and 6, the majority of countries didn't move up any special efforts to contain it, or create local, and distribute regionaly the stocks of meds/...

I see that for many it is not a big deal if some seasonal, or pandemic, flu pass on with its deadly burden for some people,
until
some of these many is not one of them.


Even if this wave would be quoted as powerful like a seasonal flu,
because of the inesistant vaccines to it, it is dangerous.

If a seasonal flu have deadly outcomes with a vaccinated ~10-15% of the population,
the actual novel flu WITHOUT any vaccine, could than have much more.

Why to minimizing, instead of trying to prepare/treat .

 

[deerskie]

Re: WHO under fire over flu alert system

Sounds like they need a two-tiered system that indicates degree of spread and also the severity; e.g., Level 6, Severity 1, would indicate a full pandemic of a virus with relatively low CFR. But then their recommendations would have to be changed too. More severe measures would be called for in the case of a Level 1, Severity 6 than for a Level 6, Severity 1, correct? Seems like you'd also need a "Severity Unknown" as well, which might trigger a different of responses than say a Severity 1 or 2.

 

[Vibrant62]

Re: WHO under fire over flu alert system

Your suggestion is good. However, even this 'mild' pandemic may yet stretch resources and lead to crises, even if it never gets any worse in terms of virulence.

In my opinion, any revision to the system should wait for some period of time to allow the world and its governments to assess the impact of this 'mild' low CFR outbreak in a 'Just In Time' global economy. We are still in the very early days of this outbreak, and the numbers involved are low - and will be in a much better position to learn from the experience, impacts, and consequences of the present system after this is over and this influenza virus has run its course.

 

[deerskie]

Re: WHO under fire over flu alert system

Your suggestion is good. However, even this 'mild' pandemic may yet stretch resources and lead to crises, even if it never gets any worse in terms of virulence.

In my opinion, any revision to the system should wait for some period of time to allow the world and its governments to assess the impact of this 'mild' low CFR outbreak in a 'Just In Time' global economy. We are still in the very early days of this outbreak, and the numbers involved are low - and will be in a much better position to learn from the experience, impacts, and consequences of the present system after this is over and this influenza virus has run its course.

Agreed, our lack of experience with pandemics in the modern age is a real problem. Still, the risks of any outbreak (attack rates, CFRs, degree of spread, etc.) can only be "estimated" at any given moment, and I believe WHO and CDC should be required to communicate their best estimates to the public. And the public was certainly confused by the current alert system. Also, these different levels also represent different "types" of outbreaks, i.e., high-spread low-severity might call for a different set of responses than a low-spread high-severity outbreak. For example, low-spread high-severity would seem to call for strict containment measures, whereas with high-spread low-severity such measures would be not only needless but unlikely to work.

As a rough mental exercise, under a two-tiered system, the current outbreak might have gone something like the list below (in parentheses, the overall "level" of precautions that would be triggered):

Level 2, Severity Unknown (fairly high because of the "Severity Unknown")
Level 3, Severity 3 (no change)
Level 5, Severity 2 (lower because of drop in estimated severity)
Level 6, Severity 1 (lower still, because of further drop in estimated severity)

This would have conveyed clearly that although the virus was spreading rapidly, the estimated severity was in fact going down.

Actually, upon further thought, I believe there should be a uniform alert system that would also be applied country by country.

 

[Vibrant62]

Re: WHO under fire over flu alert system

Sounds good in principle - but until the world has had time to assess what the impacts are of a 'mild' CFR pandemic, we can't know what measures should be applied to any new system.

The issues seem twofold
a) alerting nations to prepare
b) communicating to the world at large and the public as to what the alert system means and the threat that the potential pandemic virus poses, and what this should mean to individuals and governments in terms of the actions that they then take.

It is this second point that needs work - that of communication. IMHO this will always be a conundrum as unless there is plenty of early warning through better surveillance (and isolated human cases, as has been the case with H5N1), the severity and clinical course and progression of the potential pandemic influenza virus cannot be known until it actually happens and breaks out.

That means that under the precautionary principle, you would have to assume a severe virus is in the offing (when something appears out of the blue) until proven otherwise, which is largely what we have had to date from WHO.

I am sure that improvements to the system can be made, and mistakes will be learned from - however I am not sure that now is the time to start making them. No doubt this will be the subject of a lot of discussion and debate in a year or so when a more complete picture has emerged.

 

[RiSi]

Re: WHO under fire over flu alert system

The decision to announce a PHEIC can be summed up by:

S = Serious health consequences
U = Unusual/unexpected
I = International scope
T = Travel and trade consequences

Working from an objective perspective, a mild flu that is highly contagious can cause much more disruption (in terms of public anxiety, panic and general absenteeism) than one with lower transmission rates but a higher mortality.

The fact that H1N1 (currently) has a low mortality rate should be only one factor in the WHO decision to announce a PHEIC and start using the scale. To introduce more conditions, e.g. scale of lethality, is to hamstring the ability for WHO officials to use their judgement about what constitutes a PHEIC, and could cause confusion. The IHR 2005 was an attempt to give officials more freedom to create alerts, e.g. allowing the WHO to use evidence from non-government sources in their decision.

I see this as a public information/education issue rather than a fault of the system itself, which seems to work fairly well for what it was designed to do.

The alert system wasn't designed to be a public-friendly communication tool. It is a functional scale designed to give guidance to national health org's about minimum, fairly generic, actions (which needs to be coupled with on-the-fly recommendations tailored to unique traits of the particular PHEIC at any one time).

Maybe they should work on a public comms scale of alerts, but separate it from the functional guidelines.

 

[deerskie]

Re: WHO under fire over flu alert system

Working from an objective perspective, a mild flu that is highly contagious can cause much more disruption (in terms of public anxiety, panic and general absenteeism) than one with lower transmission rates but a higher mortality.

That's the point: "widespread/mild" and "localized/severe" outbreaks have different TYPES of risks, and should perhaps trigger different responses.

I mean, "Level 2" is meaningless without some indication of severity. That was a major source of the confusion: As the level was raised from 3 to 5, there was a public perception that things were "much worse" but what exactly did that mean?

Also, the two-tiered system gives you someplace to go based on future developments. For example, if there's an increase in h1N1 deaths, indicating a possible increase in severity, the level might be raised from "Level 6-Severity 1" to "Level 6-Severity 2" or whatever.