Pandemic flu — communicating the risks
The Bulletin interview with Dr Margaret Chan.
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.
Q: WHO has convened a series of meetings 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 exclusively on pandemic communications. It was the first step in building a global communication infrastructure to respond to the myriad challenges posed by a human influenza pandemic.
Q: Health ministries in many countries are concerned that they may be communicating 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 considerable 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 openly about a pandemic threat may raise concerns worldwide, we would not be fulfilling our public health mandate 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 communications guidance available [for governments]. WHO will provide technical and communications advice regarding public information campaigns specifically on avian and pandemic influenza.
Q: How can governments 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 consumption 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 oseltamivir 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.
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 ultimately 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 address 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 experience 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 report 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 advising governments on the use of masks in the event of a human influenza pandemic or other infectious diseases?
A: Because the pandemic virus has not yet emerged, there is no such specific guidance at the moment. While WHO has existing recommendations for issues, such as personal hygiene and mask usage primarily for health healthcare 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 recommendations that WHO provides in the pre-pandemic period, and even once the pandemic 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 implementing control measures.