The Boston Globe

ALTHOUGH Massachusetts recorded its first swine-flu death this month, the effect of the disease has not been as dire as many feared. As a result, public health officials have been able to view the health system’s response to the pandemic as a test case for an even more dangerous outbreak of flu. Among the lessons learned is the need for better coordination between the public-health sector and the private suppliers of the tools needed to contend with flu: face masks, swabs, and antiviral medicines such as Tamiflu.

Doctors, clinics, and hospitals need better, up-to-date information about the availability of commercial medicine stockpiles. Inevitably, an illness like flu that strikes patients with varying intensity will be treated in settings ranging from the home to hospital critical-care units. This increases the need for public officials to have a better fix on how quickly supplies of medicines, in particular, are being depleted and how best to blend public and private stockpiles. Officials should consider mandated reporting by commercial suppliers if necessary.

This month also saw the first swine-flu death outside the Western Hemisphere – in Scotland. So far, the disease has claimed fewer than 200 lives globally, far below the 250,000 to 500,000 who die annually around the world during a regular flu season. Still, the World Health Organization declared swine flu a pandemic June 11 because the virus is now undergoing communitywide transmission in both North America and Australia.

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I was away from last Thursday until Sunday, and without internet access. I wasn’t off the grid, just visiting my brother and his wife, but I didn’t feel like going through the hassle of tracking down their router key to get online. Sunday night and Monday morning were my first exposure to the pile of “IT’S A PANDEMIC” news. Rather than rehash, since most readers who are interested in pandemic news have already seen it, I figured I’d link to the more compelling stories I encountered when I got back online. If nothing else this post will serve to illustrate some of the places I look for information. Due to the number of links I’m just copying titles and attaching the link to them. Also, these are in the order I found them, which may or may not be related to the initial publication.

• Quickly Noted: It Begins (Continues)
• What a Pandemic Means in U.S.: Keep Doing What We’re Doing
• Swine Flu: Officially a Pandemic
• Health Officials Struggle to Estimate Need for Flu Supplies
• Going to phase 6
• We’ve Only Just Begun
• Chan Declares Level 6, Calls Pandemic `Moderate’ Severity
• WHO declares swine flu a pandemic, warns moderate severity expected
• World now at the start of 2009 influenza pandemic
• WHO counts to six
• Statements by HHS Secretary Kathleen Sebelius and DHS Secretary Janet Napolitano on WHO Decision to Declare Novel H1N1 Virus Outbreak a Pandemic
• WHO declares swine flu pandemic – BBC
• WHO declares swine flu pandemic – Guardian
• WHO: Swine flu pandemic has begun, 1st in 41 years
• World Health Organization Calls Swine Flu Outbreak a Pandemic
• Declaring a pandemic
• Flu Pandemic Is Declared — First Time in 41 Years
• WHO: Swine flu now a pandemic
• Swine flu is officially a pandemic. But don’t worry … not yet, anyway

Now keep in mind, those are only the ones that dealt mostly with reporting on the declaration (as opposed to fallout, next steps, or editorializing – if I’d included those we’d be here all week). For better or for worse, this is BIG NEWS. Tomorrow I’ll add some of my personal thoughts on what this means.

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Yesterday I threw out a sampling of the stories I’ve read in the last day or so about the WHO decision to declare a pandemic. Today I will be more editorial and get into what it means, from my point of view.

In a post a couple of weeks back I gave my thoughts on some of the controversy the WHO was dealing with at the time, the “will they or won’t they” declare the H1N1 outbreak officially a pandemic. At the time the main problem the WHO was faced with was the fact that they had crafted a pandemic alert system that was based solely on the spread of illness. Their system didn’t take severity into account. My take was that the people developing the system had done so either consciously or subconsciously based on H5N1, with its high case fatality ratio. The pieces I have read that are critical of the decision to declare a pandemic have focused in on this point. They have pointed to the 145 deaths and argued that we can’t be in a pandemic because pandemics come with so many dead and dying that the social order will break down.

This is a beast of our own making.

I have been in public health, working on pandemic preparedness, so I know just how hard it was to get people who weren’t epidemiologists or other public health professionals to take the potential impact of a pandemic seriously. I also know how much easier it is to make the point that preparedness is important by focusing on the worst case scenarios – not only in pandemics but in everything (the category 5 hurricane, the 9.5 earthquake). Add these two together and you have the common impression that a PANDEMIC (the catastrophic type we talked about as opposed to the textbook definition) is an illness on such a massive scale that society itself will fall apart.

Now that we’re facing a pandemic that doesn’t meet that criteria the skeptics are proven right. Or at least, so they will argue.

As is often the case, if you prepared for the disaster that hits you, your preparations look wasted. The easiest time to judge preparedness efforts is when they fail. If done right, proper preparation can leave you wondering if you overestimated the threat in the first place. Personally, I think that we have mostly done the right things when it comes to pandemic preparedness:

• Education – While this could have been done better, the publicity over pandemic preparedness efforts, the risk, the chaos in the streets stories on the nightly news all served to make the public aware of what a pandemic could be. I doubt that it motivated many to actually prepare their own households to shelter in place, but at least the basic, Pandemic 101 part of things was done before the first outbreak.
• Planning – The Federal government and agencies, states, and localities all have plans in place. Many of them are draft, many have unwarranted assumptions, and most have holes that you could drive an SNS delivery truck through, but they exist. People at all levels have thought about some of the tough questions and while they may not have answered them at least they are aware the questions exist.

Was declaring a pandemic the fear-mongering that some have claimed? a political action to justify the money (and there’s been a lot of it) invested? I don’t believe so. I would argue that many of the people involved would probably be happier if the declaration hadn’t been made. We have no higher level to go to, there is no 11 on this amplifier. But the system is what it is, and changing it now would just continue to elicit complaints from other people that the lack of a declaration was politically motivated to avoid embarrassment or other reasons.

So what now? We continue on as we have, monitoring the situation. If it stays as mild as it has been then in a few months time when the WHO determines that the pandemic has passed we sit down and rewrite the guidance to include some sort of severity scale along with the geographic one. If it doesn’t remain mild, if it kicks into high gear as the cool weather returns to the northern hemisphere, we batten down the hatches and ride it out.

Either way, there will undoubtedly be plenty of material for reviewing and investigating when it’s all said and done.

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“It came as no surprise on Thursday when the World Health Organization declared that the swine flu outbreak had become a pandemic,” The New York Times reports. Swine flue has “reached 74 countries, and probably met the technical definition of a pandemic — or global spread – weeks ago. ” Raising the alert from Phase 5 to Phase 6, the highest possible level, “does not mean that the illness, which has been mild in most people, has become any worse,” because “the term pandemic reflects only the geographic spread of a new disease, not its severity.” But it does “signal to countries to step up their efforts to deal with the disease,” and it “also means that the health organization is asking drug makers to start making vaccine as quickly as possible.” Dr. Margaret Chan, Director-General of the WHO, said while the disease has been mild so far, it “could change at any time and become more severe.” It may also prove more deadly “when it reaches poor countries with higher rates of malnutrition, AIDS and other diseases that can lower people’s resistance to infection. Dr. Chan said rich countries should help poor ones less able to protect themselves” (McNeil and Grady, 6/11).

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WHO has declared that the spread of the H1N1 (swine) flu virus has reached pandemic level, the AP/Google.com reports (AP/Google.com, 6/11). The Phase 6 pandemic alert indicates that two regions of the world are experiencing significant outbreaks, according to the Wall Street Journal. The declaration came after WHO held an emergency meeting Thursday about raising the threat level. The Wall Street Journal writes that the WHO wants to “eliminate misunderstandings about the virus to prevent overreactions in some countries” (Esterl, Wall Street Journal, 6/11).

According to Bloomberg, leaders from six countries infected with the H1N1 virus were briefed by the WHO yesterday and “asked for information on cases and measures taken to mitigate the disease” (Gill/Gale, Bloomberg, 6/11). WHO spokesman Dick Thompson told Reuters that WHO Director-General Margaret Chan “is looking for some detailed epidemiological explanation for what is going on.” Reuters writes, “Chan had sought further information from some countries to clarify news reports that they were detecting sustained transmission of the new virus in the community, and not just imported cases, [Thompson] said” (Nebehay, Reuters, 6/10).

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WHO today declared we an influenza pandemic is underway (aka, phase 6), which is not news to anyone. This beast has been barreling long for at least 3 or 4 weeks and the reluctance to call it what it was was related to resistance from some of WHO’s member states (the UK, China and Japan have been often fingered as the chief culprits). The apparent lack of cases in Europe didn’t fool most experts. The EU was using a testing protocol designed to minimize the case count. It was refreshing not to have the US party to these kinds of shenanigans, but of course we had no opportunity: it started here in North America. Still, US health authorities have so far acquitted themselves fairly well. We are all in uncharted territory, and communicating risk when you don’t know the size or nature of the risk, is, well, risky. CDC continues to gather information and advise federal agencies, especially regarding general recommendations and vaccine issues. All pretty useful, but as we move into the heart of this pandemic, it will become of increasingly marginal value. The brunt of the pandemic will have to be managed locally. And there were are in big trouble.

Since the Reagan era we have been systematically disinvesting in the public sector and particularly in public health and the social safety nets that catch the weak and sick as they fall. It’s a Republican idea but too many cowardly and weak Democrats threw their lot in with these enemies of public health. Clinton did little to reverse it and in some ways accelerated it. The coup de grace, of course, was reserved for George W. Bush and the Republican congress post 1994, who pulled the trigger with satisfaction and enjoyment. Now we will all suffer the predictable consequences.

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The World Health Organization (WHO) told its member nations it was declaring a swine flu pandemic Thursday, as infections continued to climb globally. This is the first global flu epidemic in 41 years.

On Wednesday, the WHO said 74 countries had reported 27,737 cases of swine flu, with 141 deaths. On Thursday, WHO said it decided to raise the pandemic warning level from phase 5 to 6 (global pandemic) after holding an emergency meeting on swine flu with its experts. 6 is the highest WHO alert level.

Still, in terms of deaths, the swine flu has been mild, so to speak. The last pandemic, the Hong Kong flu of 1968, killed about 1 million people. The regular form of influenza kills about 250,000 to 500,000 people annually.

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The H1N1 (swine flu) outbreak could soon be declared the first flu pandemic in 41 years after a recent jump in the number of confirmed cases in Australia, WHO officials said Tuesday, the AP/Google.com reports (Jordans, AP/Google.com, 6/9).

“The number of confirmed cases in Australia surpassed 1,200 on Monday, and the virus is no longer restricted to schools and other institutions there, suggesting that community-wide spread has begun” writes the Los Angeles Times (Maugh, Los Angeles Times, 6/10). “The total means Australia has seen a four-fold increase in a week,” the BBC reports (BBC, 6/9). “Such a spread in two regions of the world — it already has been observed in North America — is the primary criterion for raising the alert level to Phase 6,” according to the Los Angeles Times (Los Angeles Times, 6/10).

However, “Some flu experts think the world already is in a pandemic and that WHO has caved in to country requests that a declaration be postponed,” AP/Google.com writes. “On the surface of it, I think we are in Phase 6″ – the equivalent of a pandemic, WHO Director-General Margaret Chan said. The WHO on Wednesday will hold a conference call with international governments in order to confirm the latest reports that the virus has become established outside of North America, HealthDay News/Forbes reports. “Once I get indisputable evidence, I will make the announcement,” Chan said (HealthDay News/Forbes, 6/9).

“We very clearly see what is going on in Australia, but what we’re doing is working very hard to make sure that everyone is in the best position as we get closer to a Phase 6 declaration,” WHO’s acting Assistant Director-General Keiji Fukada said. Bloomberg writes, “Raising the WHO’s six-step pandemic scale to its highest level might cause people who are healthy to flock to hospitals, preventing the sick from getting care, [Fukada] said,” during a conference call with reporters Tuesday (Serafino, Bloomberg, 6/9).

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“The new swine influenza virus [H1N1], which appeared suddenly after years of warning about a potential pandemic of avian influenza, upset the WHO’s assumptions that most people have the same understanding of the word pandemic,” says the New York Times in a report that examines the difficultly health experts have had when attempting to agree upon what constitutes a pandemic.

“Generations of people have used the term to describe widespread epidemics of influenza, cholera and other diseases. But as the new H1N1 swine influenza virus spreads from continent to continent, it is clear that a useful definition is far more complicated and elusive than officials had thought,” the newspaper writes. “And what is at stake is far more than an exercise in semantics. A clear understanding of the term is central to the World Health Organization’s six-level staging system for declaring a pandemic, which in turn informs countries when to set their control efforts in motion.”

The article examines how “[j]ournals, textbooks and reference works use pandemic in discussing certain diseases, but rarely define the word” and the difficulty public health experts have when attempting to communicate risk assessment to the public. The piece also highlights several diseases that many health experts agree can be defined as pandemics, including AIDS, cholera and dengue.

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