The flu epidemic - was or was not

A number of articles criticizing the World Health Organization's decisions regarding the handling of the 1 H1N2009 influenza pandemic have surfaced recently. These articles raised serious claims against the conduct of the organization, claims most of which are unfounded or stem from ignorance of the scientific world.

On June 11, 2009, Dr. Margaret Chan (Chan), who heads the World Health Organization WHO, declared the H1N1 flu virus that was spreading around the world at the time as an official pandemic. The announcement led to the implementation of a response policy in many countries, which includes the stockpiling of antiviral drugs and preparations for mass vaccinations against the H1N1 virus. At this point, the flu was still in its "first wave" and the fear that accompanied the decision of the World Health Organization, as well as of health ministries in many governments, was that the next waves of the virus would become more contagious and violent - similar to what happened in the 1918 flu epidemic.

Today we know that did not happen. Our worst fears were not realized. The H1N1 pandemic, as serious as it was, died down during the winter of 2009-2010, creating a surprisingly weaker flu season than usual (those who want the numbers can go to the website of Centers for Disease Control). But this flu season has had some worrying changes. It didn't kill more people, the numbers were similar, but while regular flu mostly kills older people, H1N1 showed higher death rates among young adults, pregnant women, and children (part of the reason is that some adults had already been exposed to a similar virus in the past and were already vaccinated).

Another prediction that did not come true was that the H1N1 pandemic would come in addition to the regular flu season. But the usual flu did not appear this year and in fact there were almost no cases of seasonal flu. There is still no explanation as to why this happened, and it is likely that it will take several years before we get a clear answer.

The low (relative to expected) number of cases of H1N1 left large sections of the public with the feeling that the pandemic was a bit of a failure and that health organizations may have overreacted. Although this is a classic case of hindsight, the disconnect led to questions about the decisions made by the World Health Organization and especially about their decisions being free of conflicts of interest.

In early June 2010, two articles were published, one by Committee on Society, Health and Family Affairs of the European Council and the second published inBritish Medical Journal. An article by Yaffe Shir-Raz titled "Swine flu - the plague that never was" Published in YNET on 6.6.2010.

These articles raised a number of legitimate questions regarding the decisions made by the World Health Organization - was the decision to declare an epidemic justified? Were there real conflicts of interest among the experts who advised the organization? Were the conflicts of interest properly disclosed? It goes without saying that raising questions does not necessarily include guilt and judgment and contrary to the opinion presented in the media, this is not a witch hunt.

Was it right to declare a plague?

The World Health Organization actually began preparing for a flu pandemic in 1999 when it declared (in a free translation): "It is impossible to predict when a pandemic will occur. In the event that the real flu virus behaving as it did in 1918 appears a second time, even considering the progress of medicine since then, the cases of illness and death will be unprecedented."

This is where the organization's guiding principles come from - flu epidemics are unpredictable and can be very serious. Another point that was accepted even then is that any significant action to prevent the epidemic should take place before it reaches its peak. Scientific research has repeatedly shown that influenza viruses have a tendency to undergo changes (mutations) during an epidemic, local or global. These changes mean that the chance of the virus suddenly becoming more virulent and/or contagious is very real. This has happened before, most notably in the plague of 1918. No one can tell how bad a plague will be until it is too late to take meaningful action. Development and production of vaccines take several months, at least. The stockpiles of medicines will also run out quickly during an epidemic unless they create a stockpile of them.

The guiding principle therefore states - prepare for the worst, even while hoping for the best. In the case of H1N1 the epidemic was real and serious, with many deaths, and a high mortality rate among the young and healthy. But the scary change that would increase the violence of the virus did not happen. Added to this was the unexpected absence of the seasonal flu. There was no way anyone could have predicted these results.

It is an irresponsible act on the part of politicians and other leaders to treat the World Health Organization as a scapegoat, just because it failed to predict the future. Such attacks on the World Health Organization may get a politician airtime now but make preparing for the next pandemic much more difficult. Experts will not agree to risk their name if they are attacked in the event that their worst prediction does not come true. It's like suing a surgeon every time he removes a healthy appendix. This will not be good for all those future patients with the potential for appendicitis.

Such irresponsible public criticism of the World Health Organization may create a "boy who cried wolf" mentality. Too few people realize how lucky we were with the H1N1 virus of 2009. The next time the World Health Organization recognizes a disease as a pandemic there will be people, and perhaps even governments, who will ignore the recommendation under the statement that "that's what they said in 2009". Sad to say, but we may already be in a situation where there is a lack of trust in the World Health Organization due to the concerns raised against H5N1 (bird flu) six years ago and not realized. In a study published by Steelfisher and Co. It appears that there is ignorance, not only among the general public but also among health care providers, when it comes to the safety of the flu vaccine. Only 53% of the doctors asked about the H1N1 flu vaccine recommended getting it. The others advised against or sat on the fence. The researchers raised a concern that if another epidemic were to occur, many parents would choose not to vaccinate or vaccinate their children because they would think that the risk arising from the vaccine is higher than that of the disease itself, a concern that has no basis in scientific research.

What would better serve the general public is for the world's experts to think carefully about how to proceed during a potential pandemic, given all the unpredictable elements built into such a situation. We don't want to declare a pandemic every flu season, but we also don't want to be caught off guard. It is a delicate situation, and it is certainly reasonable to proceed from a point of view of caution - that is, to declare more epidemics than will turn out to be particularly deadly. The world would rather have a few false alarms than be caught off guard, like in 1918. One specific point critics have is that the World Health Organization changed the definition of "when to declare a pandemic" in honor of the 1 H1N2009 virus, removing the requirement that a pandemic must cause serious harm. Two points should be mentioned here, the first, the scientific reason for which the change was made is that the preparations cannot wait until the plague has already caused serious damage. The second point is timing. Although the change was announced in the media in April 2009, after the appearance of the first cases of H1N1 flu, the final draft of the committee that recommended the changes was submitted in February 2009, before the appearance of those cases.

Were there any conflicts of interest?

The article in the British Medical Journal raised suspicions that many of the experts whose advice led to the World Health Organization's decision to declare a pandemic had undeclared conflicts of interest. First, the claim that it was the declaration of the flu as a pandemic that activated the contracts of the companies producing the vaccines is incorrect. Many countries, including the United States, England, France, Belgium, Finland, Canada, the Netherlands and Switzerland ordered large quantities of vaccines weeks before the World Health Organization declared the H1N1 flu a pandemic. They did this based on the opinion of their experts and not the World Health Organization.

Second, the definition of what constitutes a conflict of interest stretches over a wide range of cases. For example, if an expert receives a bribe or commission for giving a favorable opinion to a commercial company, it is likely that everyone will agree that this is a dubious conflict of interest. If an expert holds shares of a company whose profits are affected by the expert's recommendation or decisions - this is also a clear conflict of interest. Virtually any case where an expert's advice or decision will directly affect his income or career. But there is a gray area between these clear contrasts and the lack of any connection to the industry. Academics and experts, especially since they are experts, are often paid to lecture, provide advice in their area of ​​expertise, or to design and/or conduct research for commercial entities. While these are "connections to the industry" they are not clear conflicts of interest, since they are often temporary connections and do not necessarily create a situation where future advice or opinion given by the expert will affect his income or career.

In the case of the three experts in question (out of a committee of 22 experts) who advised the World Health Organization on the H1N1 flu, all conflicts of interest are in the gray area. There was no bribe or commission, and there were no experts who stood to gain or lose money as a result of their advice. But many of the experts have previously advised industry and some have conducted clinical studies for pharmaceutical companies that produce vaccines or antiviral drugs. Where can we find an expert on the difficulties of mass production of vaccines who has not worked with a commercial company before? This of course did not stop the conspiracy-seeking critics from distorting the situation. Mike Adams from "Natural News"  Mike Adams of Natural News , for example, falsely claimed that the British Medical Monthly had uncovered bribery and a real conspiracy to deceive the public about the H1N1 pandemic (they didn't report anything close to that). If the reactions to the YNET article are to be trusted, public opinion leans more in this direction than the version that the monthly actually reported.

The public benefits when the best experts advise both industry and regulatory and government authorities. Treating any such connection as if it was done maliciously carries potential harm. Researchers help industry invest their research money in the most intelligent way and help authorities make rational, evidence-based decisions. There is a matter of balance here - we want to allow the experts to give the public the maximum benefit from their expertise, without creating a real conflict of interest that jeopardizes their advice.

Need for full disclosure

The gray area of ​​conflict of interest can be confusing, but it can be agreed that there should be full disclosure and transparency regarding potential conflicts of interest. The experts did disclose their conflicts of interest to the World Health Organization, but the names of the experts were kept secret, along with their potential conflicts of interest. The World Health Organization backs up this decision with the argument that the purpose of hiding the experts' identities is to protect them from pressures that may be exerted by industry parties. This decision is currently subject to criticism, but it has its advantages and disadvantages.

In conclusion

It is very easy to be wise in hindsight and claim that the declaration of the H1N1 flu as a pandemic was excessive, but the decision was responsible at the time. If in the future we find ourselves in a similar situation of an impending flu pandemic, a similar response (perhaps there could be some small changes) would be appropriate. Think about the alternatives - would you rather have the governments of the world prepare more for an epidemic that will not reach its peak, or millions of deaths that could have been prevented only because those governments were afraid of a possible audit?

The discussion about conflicts of interest should continue. It seems that the discussion has steered too far in the direction where any contact with the industry is considered a real conflict of interest, turning the issue more into a witch hunt than a sensible precaution. The discussion needs to return to a more balanced place - so that the public can benefit from the best experts in the important fields.

Scientific ignorance exists among the general public and a better understanding of the decision-making processes may lead to trust. One of the main problems in public perception is that the perfect is the enemy of the good. It seems that the public wants perfection and is intolerant of mistakes. This point leads to the attack and delay of very good, even if imperfect, results intended to protect the public.

There are quite a few commercial entities in the market today, some of them ideological, some of them fraudsters and some of them just crazy, who sell to the public medicine that is error-free and has no side effects. It's medicine that doesn't work. At least not beyond the placebo effect.

Easy to criticize, but hard to really solve complex problems. If you think the WHO's response wasn't good enough, come up with something better, something that doesn't involve the impossible like fortune-telling.

Sources

Article by Steve Novella bScience based Medicine

The magazine's news site Science