From simple to stupid

Epidemic: from the Greek, epi- (upon) + -demos (the people)

Pandemic: from the Greek, pan- (all) + -demos (the people)

Pandemic (according to the WHO): from external pressure and internal weakness, highly-virulent + "justified" panic + all + the people

The definition of a pandemic used to be simple: a worldwide outbreak of disease in excess of what would normally be expected (a global epidemic).  

The WHO even came out with a definition of worldwide spread (community transmission in 2 or more WHO regions).

But now, apparently, the WHO intends to change the definition of a pandemic from simple to stupid.

Bowing to pressure from member nations, the WHO is (according to the New York Times) going to change the definition to include the severity of disease, and will probably do so in such a way that the current H1N1 outbreak will never count as a pandemic (unless it becomes more virulent, which it very well might).

Now, you may remember that we've had three pandemics in the last century, one in 1918, one in 1957 and one in 1968... or, at least, that used to be true.  If this new definition goes into effect as described, we'll have to erase those last two from the list, because they were no more severe than this new H1N1 strain appears to be right now.

Whether a given outbreak is a pandemic or not is a separate question from how severe that pandemic is.  

If the WHO thinks a severity scale would be useful, then by all means they should create one. There are some good arguments against using a severity scale (flu viruses evolve so quickly, severity varies between and within countries, etc.), but it's possible a severity scale would help countries and communities to better plan for and respond to a pandemic... but the role of a severity scale should be to better describe an existing pandemic, not to determine whether an outbreak is a pandemic.

If the WHO goes through with this, there will be two definitions of a pandemic: One used by epidemiologists and other public health professionals, and one used by the WHO --because the WHO's new idea for a definition doesn't make any rational sense.  By setting up such a situation, the WHO will be undercutting its own credibility in a time when its ability to lead is more important than ever.

Instead of caving to the pressure of politicians from the member nations who feel that declaring a pandemic would cause "unjustified panic," the WHO should be using this as a teachable moment, to educate the public about what a pandemic is, what can be done about it, and why panic is never a justified reaction regardless of severity.

   

Edging closer to Phase 6, an Official Pandemic

The BBC just reported that there has been a confirmed case of human-to-human transmission in Spain. 

Here is the definition of Phase 6:

Phase 6, the pandemic phase, is characterized by community level outbreaks in at least one other country in a different WHO region in addition to the criteria defined in Phase 5. Designation of this phase will indicate that a global pandemic is under way.

"Community level outbreaks" are "sustained disease outbreaks in a community," and that criteria hasn't been met by this case; we'd need to see more than one generation of human-to-human transmission before we could call it a sustained disease outbreak in this community, but hope is swiftly waning that this outbreak will fail to become a pandemic --especially since we haven't been able to contain it in the Northern Hemisphere, where the flu season is coming to an end.

Today also saw the first confirmed death from the H1N1 strain in the US, a toddler from Texas.  My heart goes out to the parents and to the families of all of those who have died in Mexico, already.  I hope that not too many more of us will have to face what they've been through.

Phase 4 Pandemic Alert - Is this the right level?

Yesterday, the World Health Organization (WHO) in an emergency meeting raised the pandemic alert level to Phase 4 (statement here).  

The practical difference in the US was pretty much nil, since we have active cases to contend with already, but in some countries this is likely to lead to a stepped-up response.  

Because the WHO's pandemic alert level is written into some national pandemic flu plans as a trigger point for specific actions, it is a relevant issue and it's worth considering whether Phase 4 is the right level at this time.

Here is the definition for Phase 4:

Phase 4 is characterized by verified human-to-human transmission of an animal or human-animal influenza reassortant virus able to cause “community-level outbreaks.” The ability to cause sustained disease outbreaks in a community marks a significant upwards shift in the risk for a pandemic. Any country that suspects or has verified such an event should urgently consult with WHO so that the situation can be jointly assessed and a decision made by the affected country if implementation of a rapid pandemic containment operation is warranted. Phase 4 indicates a significant increase in risk of a pandemic but does not necessarily mean that a pandemic is a forgone conclusion.

We certainly seem to meet this criteria with the outbreaks in Mexico, but let's take a look at Phase 5:

Phase 5 is characterized by human-to-human spread of the virus into at least two countries in one WHO region. While most countries will not be affected at this stage, the declaration of Phase 5 is a strong signal that a pandemic is imminent and that the time to finalize the organization, communication, and implementation of the planned mitigation measures is short.

We meet this criteria, as well, with the outbreak in Mexico and laboratory-confirmed human-to-human transmission from husband to wife in Kansas.  Both countries are in the Americas Region.

We don't yet meet the criteria for Phase 6 --or at least we can't confirm that we do:

Phase 6, the pandemic phase, is characterized by community level outbreaks in at least one other country in a different WHO region in addition to the criteria defined in Phase 5. Designation of this phase will indicate that a global pandemic is under way.

As they said over at Effect Measure, "... [the] WHO has been timid and slow" in responding to this crisis, and with this decision it seems they're continuing in that pattern.  

I realize that there are political and economic costs attached to moving to Phase 5 and that, with the world economy in shambles, this is an especially difficult time for the global community to have to face those costs.  But what does it do for the credibility of the WHO when anyone who can read can plainly see that we should be in Phase 5 by the agency's own definition?  

The World Health Organization does a tremendous amount of good in the world and they have an important role to play in managing this outbreak.  It's time for them to refocus and re-emerge with the courage to do this job as only they can; they should start by following their own guidelines.