Academic journal article Bulletin of the World Health Organization

The Elusive Definition of Pandemic influenza/L'insaisissable Definition De la Grippe pandemique/La Evasiva Definicion De la Gripe Pandemica

Academic journal article Bulletin of the World Health Organization

The Elusive Definition of Pandemic influenza/L'insaisissable Definition De la Grippe pandemique/La Evasiva Definicion De la Gripe Pandemica

Article excerpt

Introduction

In 2009, governments throughout the world mounted large and costly responses to the H1N1 influenza outbreak. These efforts were largely justified on the premise that H1N1 influenza and seasonal influenza required different management, a premise reinforced by the decision on the part of the World Health Organization (WHO) to label the H1N1 influenza outbreak a "pandemic". However, the outbreak had far less serious consequences than experts had predicted, a fact that led many to wonder if the public health responses to H1N1 had not been disproportionately aggressive. (1-3) In addition, concern over ties between WHO advisers and industry fuelled suspicion about the independence and appropriateness of the decisions made at the national and international levels. (4)

Central to this debate has been the question of whether H1N1 influenza should have been labelled a "pandemic" at all. The Council of Europe voiced serious concerns that the declaration of a pandemic became possible only after WHO changed its definition of pandemic influenza. It also expressed misgivings over WHO's decision to withhold publication of the names of its H1N1 advisory Emergency Committee. (3) WHO, however, denied having changed any definitions and defended the scientific validity of its decisions, citing "numerous safeguards" for handling potential conflicts of interest. (5)

At stake in this debate are the public trust in health officials and our collective capacity to respond effectively to future disease threats. Understanding this controversy entails acknowledging that both parties are partially correct, and to resolve it we must re-evaluate how emerging threats should be defined in a world where the simple act of labelling a disease has enormous social, economic and political implications.

What sparked the controversy

Since 2003, the top of the WHO Pandemic Preparedness homepage has contained the following statement: "An influenza pandemic occurs when a new influenza virus appears against which the human population has no immunity, resulting in several simultaneous epidemics worldwide with enormous numbers of deaths and illness." (6) However, on 4 May 2009, scarcely one month before the H1N1 pandemic was declared, the web page was altered in response to a query from a CNN reporter. (7) The phrase "enormous numbers of deaths and illness" had been removed and the revised web page simply read as follows: "An influenza pandemic may occur when a new influenza virus appears against which the human population has no immunity." Months later, the Council of Europe would cite this alteration as evidence that WHO changed its definition of pandemic influenza to enable it to declare a pandemic without having to demonstrate the intensity of the disease caused by the H1N1 virus. (3)

A description versus a definition

Harvey Finebirg, chairman of a WHO-appointed International Health Regulations (IHR) Review Committee that evaluated WHO's response to H1N1 influenza, identified the definition of pandemic influenza as a "critical element of our review". (8) In a draft report released in March, the committee faulted WHO for "inadequately dispelling confusion about the definition of a pandemic" and noted WHO's "reluctance to acknowledge its part in allowing misunderstanding" (9) of the web page alteration, which WHO has characterized as a change in the "description" but not in the "definition" of pandemic influenza. "It's not a definition, but we recognize that it could be taken as such ... It was the fault of ours, confusing descriptions and definitions", (10) a WHO communications officer declared. Indeed, the Council of Europe was not alone in claiming that the "definition" had been changed. (7,11,12)

WHO argues that this phrase--which could be more neutrally referred to as a description-definition--had little bearing on policy responses, a WHO press release states that it was "never part of the formal definition of a pandemic" and was never sent to Member States, but simply appeared in "a document on WHO's website for some months". …

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