The dust is now settling on the H1N1 "pandemic." After all the ballyhoo, the impact of H1N1 was not very different from that of a typical seasonal flu. There were more young people sick but a lot fewer older people sick and no health-care crisis or economic or social collapse.
Some European politicians are alleging that pressure from drug companies led the World Health Organization to overshoot. Indeed, pharmaceutical and medical supply companies heavily profited. But, despite the appeal of a conspiracy theory, we believe the fundamental error was a rigid adherence to pre-existing pandemic plans.
OVERSHOOT #1: DEFINITION OF A PANDEMIC
The power of words is enormous. Much of the worldwide overreaction to H1N1 can be traced to the WHO's zeal to declare a "pandemic." Just before the new H1N1 was identified, the WHO made a subtle but important change in its own definition of "pandemic." It dropped the key requirements that a pandemic virus had to be completely novel - an antigenic shift - and cause widespread and severe disease. These were characteristics of previous pandemics.
Almost immediately, as luck had it, a virus appeared that fit the new pandemic definition - but not the old one. The difference turned out to be crucial. Most of the older population had been exposed to a similar virus that circulated for many years before 1957 and were protected from the new H1N1. As a result, the people most vulnerable to severe disease were largely spared.
This pattern was obvious from the start, when the number of deaths in Mexico was far lower than the tens of thousands predicted by pandemic plans. Ignoring the rapidly accumulating contrary evidence, the WHO took the position it had to adhere to its new definition. Once a pandemic was declared, there was no turning back. On WHO instructions, all countries dutifully activated their pandemic plans.
OVERSHOOT #2: EVERYONE 'NEEDS' VACCINE
World pandemic plans, which are designed to respond to catastrophes, called for mass immunization. These plans were followed religiously, even as H1N1 proved far milder than expected. Moreover, by early October, it was obvious that the vaccine would not arrive until the peak of the outbreak and then, initially, in small amounts. This called for a change in plan. The focus for immunization needed to shift exclusively to those at high risk - specifically, people with serious underlying chronic diseases.
The "worried well" needed to hear the bad news that they would not get the vaccine in time and the good news that they really didn't need it. Instead, our public health leadership wanted to have it both ways. They terrorized the public with exaggerations and misinformation, then tried to limit clinics to a high-risk minority. Chaos ensued.
OVERSHOOT #3: CARRY ON REGARDLESS
The H1N1 outbreak peaked in October, and disease rates dropped off rapidly in North America. Any benefit from immunizing healthy people had virtually vanished by mid-November, the very time when the vaccine became readily available to all. Speculation about a serious "third wave" is fading fast, as high population levels of immunity make it implausible.
Instead of sharing the good news - the danger has come and gone for otherwise healthy people - the current risk is exaggerated to justify ongoing futile vaccination efforts directed at the worried well.
Total deaths worldwide from H1N1 probably will end up lower than from typical seasonal flu. Yet, the WHO still labels this a moderate pandemic and has no plans to downgrade or simply call it off.
To be fair, a modicum of pandemic planning served a good purpose during the WHO's initial response. The WHO quickly moved into Mexico to gather information. International laboratory co-operation led to rapid identification of the H1N1 virus. Surveillance capabilities were enhanced worldwide, and countries quickly detected H1N1 in their midst. The impossibility of containment was quickly acknowledged, and futile travel advisories were discouraged. Vaccine development was started quickly.
It was once said that no plan survives the first five minutes of any battle. What this means, of course, is that any plan can be quickly superseded by events. The good public health leader, like the good general, needs to put more value on utilizing new information and less on simply following orders. This is the real lesson of H1N1.
Richard Schabas was Ontario's chief medical officer of health from 1987 to 1997. Neil Rau is an infectious diseases specialist and medical microbiologist in private practice in Oakville, Ont., and a University of Toronto lecturer.Report Typo/Error
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