Committee reviews International Health Regulations and the response to H1N1

h1n105 July 2010

Last week the International Health Regulations Review Committee established to probe into the international response to H1N1 pandemic influenza held its second meeting at WHO Headquarters in Geneva. Global Health Europe was present to monitor the segments of the meeting accessible to journalists. The International Health Regulations (IHR) is an international legal agreement that is binding on 194 States Parties across the globe. The basic purpose of the IHR is to help the international community prevent and respond to acute public health risks that have the potential to cross borders and threaten people worldwide. The H1N1 pandemic is the first public health emergency of international concern to occur since the 2005 revised IHR came into force. In January 2010, the WHO Executive Board called for an independent review of the IHR.

Specifically the IHR Review Committee was established with three objectives: to assess the functioning of the IHR; to assess the ongoing global response to the pandemic H1N1 (including the role of WHO); and to identify lessons learnt important for strengthening preparedness and response for future pandemics and public health emergencies. The IHR Review Committee is independent of the WHO and is made up of approximately 29 members representing a broad mix of expertise, practical experience and backgrounds, and includes experts from developed and developing countries.

Between 30 June and 2 July 2010 the IHR Review Committee conducted interviews with 30 individuals from national governments, international organizations and from pharmaceutical industry associations. In general, interviewees summarized their activities in response to H1N1 and reported that interactions with the WHO had been very useful throughout the pandemic. Concerns raised by interviewees were primarily in regard to the timely production of vaccines in sufficient quantities, equitable access to vaccines and other benefits, and the transparency of WHO processes.

Ambassadors Gomez-Camancho of Mexico and Angell-Hansen of Norway, co-presidents of the open-ended working group on pandemic influenza preparedness: virus exchange and access to vaccines and other benefits, reported to the Review Committee on the working group's findings to date. There has been a concern since the negotiation of the IHR that poorer countries would lose out to the interests of rich countries in the race to secure vaccines for one's population. The Mexican Ambassador felt that the H1N1 pandemic presented evidence of this outcome. In accordance with IHR Mexico promptly shared virus samples of H1N1 with the WHO, which then distributed these "seed" viruses for vaccine production to laboratories across the world with the capacity to produce pandemic influenza vaccines. Despite this cooperation Mexico found it difficult to procure vaccines for its population once they were ready.

One complicating factor was that vaccine yields from the seed viruses had not been as high as anticipated. This coincided however with pre-order agreements that wealthy countries had made with pharmaceutical firms which meant that a major portion of vaccine produced was already sold before it was even available. These two factors lead to a global shortage in vaccine supply-the consequences of which where not borne equally between countries. In this light we have been extraordinarily lucky that H1N1 turned out to be much less severe than anticipated, noted Ambassador Angell-Hansen. The experience presents an opportunity to learn lessons without catastrophic loss of life.

Preservation of life, however, in not the only concern when it comes to vaccines production. When a government releases samples of a seed virus for vaccine production it is also providing an opportunity for a handful of companies which have the capacity to produce pandemic vaccine on a massive scale to generate vast amounts of income. "we have spoken about virus sharing [in WHO negotiations]," said Ambassador Gomez-Camancho, "now it is time for us to speak about benefits sharing."

Representatives from the International Federation of Pharmaceutical Manufacturers and Associations (IMFPMA) and the Developing Countries Vaccine Manufacturers Network (DCVMN) were also interviewed. They described some of the obstacles which manufacturers face in producing pandemic flu vaccines. One of the greatest challenges is the lack of capacity to produce enough vaccines to satisfy global demands. It takes about 6 months to produce a vaccine for pandemic influenza and manufacturers cannot achieve this in a timely manner unless they have facilities that are already active. This means that to produce pandemic influenza vaccine you must already be in the business of producing seasonal influenza vaccine. This may not be a problem for labs in Europe and North America where there is an active annual use of seasonal flu vaccine, but this is not the case in countries like India where flu vaccine is not regularly in demand. Serious attention is needed to find solutions for the lack in capacity that also addresses geographical disparities.

Vaccines however are not the only effective response to controlling a pandemic influenza outbreak, as an interviewee from the Japanese Ministry of Health explained. Japan had a notably low rate of mortality for H1N1. While Japan has been criticized for it's aggressive actions at airports (disruptive measures which agreements like IHR are meant to prevent), the Japanese governments points to the discipline with which the Japanese population carried out preventive measures. Contrary to what is the norm in other regions, the Japanese consistently used face masks, and regularly washed hands and disinfected doors and hand railings in offices, schools and other public buildings. These are also lessons which should not be lost, though issues regarding vaccines draw more attention.

Further comments from interviewees concerned improvements that could be made in the WHO system for communication and media liaison. The life cycle of a pandemic is communicated by WHO as a series of 6 phases. One problem is that the WHO maintains only one phase of the pandemic at any given time, when in reality the experience will vary between countries and regions. This can create confusion, inaccurate reporting in the media, and unnecessary worry in the population. There is also the problem of lag time of up to 24 hours between when the WHO emergency committee makes a decision to raise the pandemic phase and when WHO publically announces this decision. This lag time presents a risk that any information leaked to the media and announced in a sensational way could result in panic. The WHO needs to do more to ensure that it is in control of communication on the severity of pandemic risk to the media to prevent sensationalist reporting.

Dr. Paul Flynn, a UK parliamentarian who led a UK review of the response to pandemic H1N1, presented the finding of his Council of Europe report (for further information and commentary on this report see the article by Graham Lister). Flynn's main concern was the lack of transparency in WHO processes during the pandemic. WHO has come under criticism for its response to H1N1 and there has even been accusation of potential corruption as some members of the WHO Emergency Committee which decides on pandemic phases may have had previous ties to pharmaceutical industry. So far these accusations have proven to be baseless; however, Flynn argues that had the WHO been more transparent and released the names and possible conflicts of interest of the members of the Emergency Committee (information which was withheld during the crisis) they could have simply avoided this criticism.

The next meeting of the IHR Review Committee will be held in the end of September, at which time they will conduct further interviews. The Committee intends to write a report to be presented at the 64th World Health Assembly in May 2011. For updates and further information on the IHR and H1N1 pandemic response reviews visit http://www.who.int/ihr/review_committee/en/

 

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