Committee Examines Undue Influence, Coordination In WHO Pandemic Flu Response

A review of the World Health Organization’s response to the 2009 pandemic influenza outbreak kicked off this week, with firm statements from those involved in the response that they were not unduly influenced by outside stakeholders. Still, serious questions remain about the coordination effort, as a nearly a year after the pandemic was declared developed countries find themselves having to dispose of excess vaccines while poorer countries are reporting they have yet to obtain as many as they need.

The response to the global spread of H1N1, or “swine flu”, is being examined under the rubric of reviewing the WHO International Health Regulations. The final report of the 29-member expert body [pdf] tasked with the review is not expected until the World Health Assembly in May 2011, but this meeting was the start of a process intended to improve responses to future health emergencies.

This week’s meeting ran 11-14 April. Future meetings are planned for three consecutive days during the week of 28 June and again during the week of 27 September, though exact dates are not yet decided. Between meetings the expert group is expected to gather information, including from intergovernmental agencies and non-governmental groups.

Meanwhile, the pandemic is still ongoing, the expert review body was told by John MacKenzie, the chair of International Health Regulations (IHR) Emergency Committee, an advisory body tasked with providing recommendations to the WHO director general in cases of global emergency. The Emergency Committee is waiting for more evidence from the Southern Hemisphere to asses what they say is an ongoing threat, and is “not at any stage yet where we would terminate the public health emergency,” he said.

As the Emergency Committee was an important part of WHO’s response effort, their actions will be one of the many areas analysed by the review body.

Review Committee

The review committee experts are questioning the details of the WHO’s response to the H1N1 to determine if it was handled as well as it could have been. The mild nature of the virus has left many wondering if the threat was exaggerated, and there has been speculation that the thread was deliberately trumped up in order to trigger the production of pre-ordered vaccines to the benefit of the pharmaceutical industry (IPW, Public Health, 26 January 2010).

But this possibility was vehemently rejected by MacKenzie, who told the review body “I was not approached by anyone in the pharmaceutical industry.”

The Emergency Committee members’ names were kept secret, MacKenzie said, in part to prevent the possibility of such conflicts of interest. “My name was the only one known outside the committee, and so I was the only one who could have been approached. And I certainly wasn’t.”

The examination work of the review committee is so far divided into five areas: the preparedness phase, the alert phase (everything leading up to the declaration of “pandemic”), the response phase, communication (including with the public and the press), and aspects of the International Health Regulations outside influenza, review committee Chair Harvey Fineberg told a press conference immediately following the 11-14 April meeting. Fineberg is president of the Washington, DC nonprofit The Institute of Medicine.

One issue that received several questions during the review committee on 14 April was on whether the WHO had changed its definition of “pandemic.” In particular, the WHO has been accused of altering its guidelines – which were updated in April 2009 from an earlier 2005 [pdf] document – to remove references to the severity or seriousness of the disease. WHO has denied these accusations, saying that the definition of pandemic has never changed (IPW, WHO, 25 January 2010).

WHO flu expert Keiji Fukuda said the organisation “always recognised that severity was important,” but that poses a practical problem. It is difficult to define and even harder to measure, and measure quickly, as is needed for a pandemic response, he said. This is especially so since severity may range widely in different populations and countries, and since influenza outbreaks often look different at the beginning than they do in the end. The organisation tries to address severity, he added, but does not hold up decisions on it.

And MacKenzie said that this pandemic “is much more severe, I believe, than people tend to talk about,” citing deaths among young, healthy adults.

Distributing Vaccines, Information

Another major question likely to come up is how vaccines and treatments can be distributed equitably.

News reports, such as this one from the Washington Post reporting that the United States has used less than half of the vaccines it purchased, have said that the US and several European countries are finding themselves with more doses of vaccine than they can use before it expires.

Meanwhile, some developing countries have said they were unable to get the vaccines they needed – notably Mexico, where the virus originated and who provided the strains needed to manufacture vaccines worldwide (IPW, WHO, 20 January 2010).

WHO’s role in facilitating technology transfer and capacity building on access to vaccines was “touched on” during this week’s discussions and is something “we expect we will be investigating, along with other topics, in coming months,” said Fineberg in response to an Intellectual Property Watch question.

Also at issue, according to conversations at the meeting, is how to communicate with media more effectively, in particular using so-called “new media” such as text messaging and blogging and practicing what a member of the committee called “rumour management.”

In a separate development, the European Federation of Pharmaceutical Industries and Associations reported the results of a pilot project to combat counterfeit medicines. The project involved labeling each medicine packet with an individualised code. The final report, available here, called the project a success.

The WHO’s Pandemic Alert Response: Emergency Committee Meetings

25 April 2009
First meeting of the IHR Emergency Committee
Declaration of “Public health emergency of international concern”

27 April 2009
IHR Emergency Committee issues temporary recommendations for flu response
Pandemic is moved from phase 3 to phase 4
Containment not considered possible; focus shifts to mitigation

29 April 2009
Smaller meeting with Emergency Committee chair, vice chair and rapporteur
Sustained transmission of H1N1 seen in at least two countries (US and Mexico)
Phase moved from 4 to 5 after agreement from full EC reached electronically

5 June 2009
Phase 5 continues, as EC did not believe there was enough information to go further

11 June 2009
Evidence of sustained transmission in at least two, if not three, WHO regions
Information received from Mexico, US and Canada as well as Spain, the UK, Japan and Australia
Phase 6 — official pandemic — declared with unanimous EC support

Recent meetings of EC on:
23 September 2009
26 November 2009
23 February 2010

Reports of these meetings are available here.