“Performance fair, but could do better.”
That’s the thrust of an outside review of the World Health Organization (WHO)’s handling of the 2009 H1N1 flu pandemic, by an expert committee which released a preview [pdf] of its findings yesterday.
Twenty-five scientists and public health experts, chaired by Harvey Fineberg, president of the Institute of Medicine of the US National Academies, formed the review committee, and released the preview to solicit comments before the committee’s final meeting on 28 March. Its final report will be presented at the World Health Assembly in May.
The WHO “performed well in many ways,” the committee’s report says. It defends the agency against allegations by critics that industry might have influenced WHO decision-making, including when to officially declare a pandemic. The review “found no evidence of malfeasance”. But it also gives a long list of areas where it says that the WHO could improve its future response to international threats to public health.
The report praised the WHO’s leadership for its response: in particular, its characterization of the emerging pandemic, its generation within weeks of the seed strains needed to create vaccines, and its rapid policy guidelines on which at-risk groups needed most to be vaccinated.
But the WHO failed to provide a “consistent, measurable and understandable” depiction of the severity of the pandemic, the committee found – something that informs both policy choices and personal decisions.
Though estimating the severity of the initial and subsequent waves of a flu pandemic is fraught with difficulties, the report says the WHO should do it, and suggests a basket of indicators such as “hospitalization rates, mortality data, identification of vulnerable populations and an assessment of the impact on health systems”. As for an indicator the WHO did use – counts of confirmed cases – these caused considerable confusion in the media and public, and are only really relevant in getting a handle on the earliest stage of an outbreak in a region. They are of little use once the virus is spreading widely within the community, as they then vastly underestimate the real number of cases.
That said, the committee challenges assertions that the WHO overstated the seriousness of the pandemic. In the early stages of the pandemic – when countries must make vaccine order decisions because it takes six months to produce vaccine – there was great uncertainty about the severity of the disease. Evidence from early outbreaks suggested a severity greater than that which finally emerged, the committee noted.
The WHO also failed to dispel confusion over its definition of a ‘pandemic’. This was, for example, described in one WHO document as causing “enormous numbers of deaths and illness,” whereas the official WHO definition is based only on the extent of global spread. An effort by the WHO to clarify matters by changing online documents to better reflect the official definition backfired, said the report, as it fuelled “suspicion of a surreptitious shift in definition.”
The WHO’s 6-point pandemic phase scale, created in 1999 and designed to help decide what actions states needed to take as the pandemic threat heightened, comes in for criticism too. The report argues that in practice it proved more useful for planning than for responding operationally to the emerging pandemic H1N1 virus. The scale itself could perhaps be simplified, it adds.
Again, however, the committee rejected allegations by critics who “accused the WHO of rushing to announce Phase 6 and suggested the reason was to enrich vaccine manufacturers,” (see Nature’s article on this here). If anything the WHO delayed declaring a pandemic until it was clear that sustained community spread was occurring worldwide, the committee says.
The review adds that the WHO had sometimes failed to acknowledge other legitimate criticisms, such as the timely disclosure of relationships potentially constituting a conflict of interest among experts who advised on plans and responses to the pandemic. The WHO kept the identities of the members of its advisory Emergency Committee confidential up-to and during the pandemic, arguing that this protected them from outside pressure. But the report says that in practice this gave rise to suspicions that the WHO had something to hide. The WHO published the members’ identities and declarations of competing interests after the pandemic was over. But prior to this information being made public, “assumptions about potential ties between Emergency Committee members and industry led some to suspect wrongdoing,” it notes.
Though none of the competing interests were important enough to merit exclusion from the committee, the WHO should adopt more transparent procedures for appointing members of expert committees with respect to potential conflicts of interest, says the report. And the identity of Emergency Committee members should be made public on appointment.
“As far as the Review Committee can determine, no critic of WHO has produced any direct evidence of commercial influence on decision-making,” concludes the review, which states that it “found no evidence of attempted or actual influence by commercial interests on advice given to or decisions made by WHO.” It adds that “In the Committee’s view, the inference by some critics that invisible commercial influences must account for WHO’s actions ignores the power of the core public health ethos to prevent disease and save lives.” The WHO had not been sufficiently vigorous in defending itself against criticisms questioning its integrity, adds the report.
For all Nature’s past coverage see our 2009 pandemic special.