Pandemic flu -- communicating the risks.

Bulletin of the World Health Organization | January 2006, 84 (1) WHO News Q: WHO has convened a series of meet- ings over the last few months on avian influenza and the threat of a human influenza pandemic. Was it necessary to hold “yet another” meeting? A: The December meeting was the first WHO meeting that focused exclu- sively on pandemic communications. It was the first step in building a global communication infrastructure to re- spond to the myriad challenges posed by a human influenza pandemic. Q: Health ministries in many countries are concerned that they may be com- municating uncertainty to the public when it comes to public information on avian influenza and human pandemic influenza? What is WHO advising them to do? A: In accordance with WHO Outbreak Communication guidelines, WHO advises Member States to be as open and transparent as possible in their public communications regarding disease threats, including avian and pandemic influenza. Unfortunately, there is consid- erable uncertainty simply because there are many unknowns about the next influenza pandemic. There is no way for anyone to accurately predict things like when the next pandemic might strike, or how many people might be killed. While WHO recognizes that talking Pandemic flu — communicating the risks Dr Margaret Chan is from China. She obtained her MD degree from the University of Western Ontario, Canada, in 1977, and joined the Hong Kong Department of Health in 1978, where she began her career in public health. She was appointed Director of Health of Hong Kong in June 1994. After two decades of working closely with WHO, Chan joined the organization as Director of the Department of Protection of the Human Environment in 2003. In June 2005, she became Assistant Director-General for the Communicable Diseases cluster of departments and took up the newly-created post of Representative of the Director-General for Pandemic Influenza. No public health issue has caught the public imagination over the last year as vividly as avian flu. Governments are scrambling to be prepared for a human flu pandemic that could kill millions of people. But public misconceptions abound about the nature of the threat to human health and how to respond to it. WHO hosted a meeting of public health experts in Geneva on 6–8 December to discuss how governments should communicate the risks posed by avian flu and the threat of a human flu pandemic to members of the public. W HO Dr Margaret Chan openly about a pandemic threat may raise concerns worldwide, we would not be fulfilling our public health man- date if we did not warn the world of this evolving threat. Q: Can Member States take a one-size- fits-all approach to communicating these risks? Or do public information campaigns need to be tailored to cultural and other specifics? How can WHO help to develop such information campaigns? A: These are some of the issues that were addressed at the 6-8 December meeting. Once working groups are established to move ahead on such issues, we will have some communica- tions guidance available [for govern- ments]. WHO will provide technical and communications ad- vice regarding public information cam- paigns specifically on avian and pandemic influenza. Q: How can govern- ments justify to the public the WHO recommendation that individuals should not stockpile the antiviral drug, Tamiflu (oseltamivir), and in the event of a human influenza pandemic, how can governments justify selecting those who receive doses and those who do not? If governments get this message across in advance, will they not be more likely to have public cooperation and success in the event of a pandemic? A: WHO does not recommend that individuals stockpile oseltamivir because this is a drug whose consump- tion requires medical supervision. National stockpiles of oseltamivir, like WHO stockpiles of oseltamivir, have a very specific public health purpose — to contain the emergence of a new pandemic strain, if possible, and to lessen the burden of death and disease. Widespread personal use of oseltami- vir could provoke the emergence of a resistant strain, which then might have serious public health implications. There is still much uncertainty regarding the potential efficacy of oseltamivir in the next pandemic. No one knows if it will be effective against the pandemic strain and it should not be regarded as a silver bullet. National authorities will have to decide which populations will be eligible to receive it according to their own criteria. Investing in pandemic preparedness is essentially like investing in an insurance policy. 10 Bulletin of the World Health Organization | January 2006, 84 (1) WHO News Q: Do you think there is too much “hype” about avian influenza and a possible human pandemic? What happens if there is no pandemic in the next six months? Will that not detract from the credibility of WHO and the United Nations? A: As a global public health agency, WHO has a responsibility to alert the international community when it appears that the world is moving closer to a pandemic. It may be years before a pandemic hits the world, and it may ul- timately be sparked by a virus other than [avian influenza virus] H5N1. Investing in pandemic preparedness is essentially like investing in an insurance policy, and while we hope that we never have to make a claim, we also know that whatever investment we make now in strengthening global public health infrastructures will have benefits for our responses to all future infectious disease threats. The preparations that we make for a pandemic are not disease specific; they will increase our capacity to respond to all future outbreaks, including SARS (severe acute respiratory syndrome) and other new and emerging diseases. Q: Some members of the public in some countries believe vaccines for a human pandemic influenza will be available as soon as a pandemic is announced. How can governments dispel the public’s unrealistic expectations about vaccine availability? A: WHO advises governments to ad- dress such issues openly and rapidly. Because the pandemic strain has not yet emerged, there is no such vaccine currently available. Since a pandemic vaccine needs to be a close match to the pandemic virus, commercial production cannot begin prior to the emergence and characterization of the pandemic virus. It is likely that vaccine production, in any significant amounts, will take at least six months. It is therefore highly unlikely that there will be any large quantities of pandemic vaccine available during the first wave of a pandemic. Q: SARS was a lesson in openness and transparency. If you are not open right away, it haunts you. Do you think governments have learned from the expe- rience of SARS, that if they are not open and transparent from the start they may be heading for disaster? A: Yes, SARS was an excellent example in demonstrating to countries that because infectious diseases do not respect borders, there is no such thing as a localized outbreak. An outbreak in one country one day can very rapidly become a problem for countries on the other side of the world. WHO hopes that countries realize that while they may be reluctant to re- port disease outbreaks, if they do so quickly and transparently, WHO can provide them with technical guidance and support, if it is needed, to contain such outbreaks. Q: How is WHO advis- ing governments on the use of masks in the event of a human influ- enza pandemic or other infectious diseases? A: Because the pandemic virus has not yet emerged, there is no such spe- cific guidance at the moment. While WHO has existing recommendations for issues, such as personal hygiene and mask usage primarily for health- care workers, such guidance is based on general transmission patterns of seasonal human influenza. It is not known how effective this guidance would be in slowing the spread of a pandemic. Thus, any recommenda- tions that WHO provides in the pre- pandemic period, and even once the pan- demic starts, may be modified once more information about the pandemic strain is obtained, such as its infection rate and its lethality. Q: How do you bring members of the medical profession on board so that those who don’t believe what public health people are saying do not contradict public health messages? A: WHO recognizes the need to work closely with medical professionals, since they are a very valuable ally in containing outbreaks and implement- ing control measures. O ... there is no such thing as a localized outbreak. An outbreak in one country one day can very rapidly become a problem for countries on the other side of the world. WHO clinical trials initiative to protect the public In response to calls for new standards and rules for the registration of studies involving humans participants, WHO is developing a common set of rules for registering clinical trials. WHO plans to launch a global network of clinical trial registers in May 2006, the first step towards establishing a web- based search platform where members of the public can obtain full and de- tailed information about clinical trials. Currently, there are at least 50 reg- isters of clinical trials around the world. The WHO International Clinical Trials Registry Platform is a major initiative to bring these registers together in a global network to provide a single point of ac- cess to the information stored in them. The goal is to increase transparency and accountability on the part of com- panies and institutions that do clinical research, and, in turn, boost public trust and confidence in that research. “Registration of trials promotes scientific and ethical integrity and makes research more honest. When the system is up and running there will be no hiding of results,” said Dr Patrick Unterlerchner, WHO Health Systems Analyst and Assistant to the Coordinator of the project. The initiative comes in the wake of several cases of companies withholding negative research findings that sparked public outrage. Merck of the United States withdrew Vioxx from the market in 2004 after the drug was linked to an increased risk of heart attack and stroke, and in 2003, GlaxoSmithKline of the United Kingdom warned that the antidepressant, Paxil, should not be prescribed to minors as it could increase the risk of suicide. In response, the International Committee of Medical Journal Editors (ICMJE), representing the world’s leading medical journals, agreed not to publish the results of any clinical trial unless that trial had been registered in a public register before the enrolment of the first patient. 11Bulletin of the World Health Organization | January 2006, 84 (1) WHO News Recent news from WHO • WHO Director-General LEE Jong-wook visited parts of Pakistan that were affected by the 8 October 2005 earthquake. He praised the response of the government and the international community to the disaster, but said that WHO still needs US$ 13 million, almost half of the US$ 27 million initially requested to help people there survive the winter. Hundreds of thousands of people still need better shelter, the cold and the crowded conditions in some camps increase the risk of respiratory infections, and getting health care to people who live high in the mountains is a major challenge. • WHO published a new report, Ecosystems and Human Well-being: Health Synthesis, on 9 December, on the complex links between preserving healthy and biodiverse natural ecosystems and protecting human health. To read the report, please see: http://www. who.int/globalchange/ecosystems/ecosystems05/en/ • Every year millions of people are pushed into poverty because of high medical costs paid for out of their own pockets. Experts from 40 countries at a conference in Berlin looked at ways to provide social protection for people who cannot afford these costs and to promote investment in health. The 5–7 December meeting was convened by the Deutsche Gesellschaft für Technische Zusammenarbeit GmbH, the German Federal Ministry for Economic Cooperation and Development, the International Labour Organization and WHO. • WHO and the UN Food and Agriculture Organization made it clear on 5 December that it is safe to eat chicken, eggs and other poultry products as long as they are properly cooked. They issued this advice to national food safety authorities after sales of poultry products fell over consumer fears that these products might be infected with a bird flu virus. • Lesotho launched a groundbreaking campaign on World AIDS Day, 1 December, to encourage everyone in the southern African country to get tested for HIV. Lesotho is offering confidential and voluntary HIV testing and counselling door-to door with the goal of reaching all households in Lesotho by the end of 2007. • With an additional US $1 billion per year, immunization could save 10 million more lives in a decade. With this increased investment, more than 70 million children in the world’s poorest countries would be protected each year against 14 major childhood diseases by 2015, according to a WHO/UNICEF study presented at the 7–9 December meeting of representatives of the Global Alliance for Vaccines and Immunization (GAVI). For more about these and other WHO news items please see: http://www.who.int/mediacentre/events/2005/en/index.html One of the largest registers, ClinicalTrials.gov, which is hosted by the US National Institutes of Health, contains some 23 000 registered trials, while the International Standard Ran- domised Controlled Trial Number Register in the United Kingdom contains some 3500. These registers hold mainly informa- tion about trials done in the developed world. A number of countries, including some from the developing world, have plans to start their own registers. “There is a clear need to consoli- date all information on clinical trials to use resources efficiently and reduce the chances that a trial might be registered in more than one register,” Unterler- chner said. He argued that WHO is best placed to do this as a global body representing 192 Member States that is able to set norms and standards in research, policy and practice. WHO does not plan to set up its own clinical trials register. The idea is for WHO to set rules and standards on how existing registers should operate and how they should work together. W HO /T DR /O . M ar te l Millions of people around the world participate in clinical trials and are affected by the results of those trials. The picture shows a group of children in Colombia who are queueing up to be given a malaria vaccine in a clinical trial in the 1990s. WHO plans to bring all the registers meeting these standards into a global register network, searchable on one WHO search portal. The portal will give sick people the chance to find out about research into their particular disease and to ask their doctors to enrol them in a clinical trial that may offer them access to innova- tive treatments that are not yet widely available. http://www.who.int/ictrp O