Round

Round table table

The elusive definition of pandemic influenza

Peter Doshia

Abstract There has been considerable controversy over the past year, particularly in Europe, over whether the World Health Organization
(WHO) changed its definition of pandemic influenza in 2009, after novel H1N1 influenza was identified. Some have argued that not
only was the definition changed, but that it was done to pave the way for declaring a pandemic. Others claim that the definition was
never changed and that this allegation is completely unfounded. Such polarized views have hampered our ability to draw important
conclusions. This impasse, combined with concerns over potential conflicts of interest and doubts about the proportionality of the
response to the H1N1 influenza outbreak, has undermined the public trust in health officials and our collective capacity to effectively
respond to future disease threats.
WHO did not change its definition of pandemic influenza for the simple reason that it has never formally defined pandemic influenza.
While WHO has put forth many descriptions of pandemic influenza, it has never established a formal definition and the criteria for
declaring a pandemic caused by the H1N1 virus derived from “pandemic phase” definitions, not from a definition of “pandemic influenza”.
The fact that despite ten years of pandemic preparedness activities no formal definition of pandemic influenza has been formulated
reveals important underlying assumptions about the nature of this infectious disease. In particular, the limitations of “virus-centric”
approaches merit further attention and should inform ongoing efforts to “learn lessons” that will guide the response to future outbreaks
of novel infectious diseases.

Abstracts in ‫عريب‬, 中文, Français, Pусский and Español at the end of each article.

Introduction What sparked the controversy

In 2009, governments throughout the world mounted large and Since 2003, the top of the WHO Pandemic Preparedness
costly responses to the H1N1 influenza outbreak. These efforts homepage has contained the following statement: “An influenza
were largely justified on the premise that H1N1 influenza and pandemic occurs when a new influenza virus appears against
seasonal influenza required different management, a premise which the human population has no immunity, resulting in
reinforced by the decision on the part of the World Health several simultaneous epidemics worldwide with enormous num-
Organization (WHO) to label the H1N1 influenza outbreak bers of deaths and illness.”6 However, on 4 May 2009, scarcely
a “pandemic”. However, the outbreak had far less serious con- one month before the H1N1 pandemic was declared, the web
sequences than experts had predicted, a fact that led many to page was altered in response to a query from a CNN reporter.7
wonder if the public health responses to H1N1 had not been The phrase “enormous numbers of deaths and illness” had been
disproportionately aggressive.1–3 In addition, concern over ties removed and the revised web page simply read as follows: “An in-
between WHO advisers and industry fuelled suspicion about fluenza pandemic may occur when a new influenza virus appears
the independence and appropriateness of the decisions made at against which the human population has no immunity.” Months
the national and international levels.4 later, the Council of Europe would cite this alteration as evidence
that WHO changed its definition of pandemic influenza to en-
Central to this debate has been the question of whether able it to declare a pandemic without having to demonstrate the
H1N1 influenza should have been labelled a “pandemic” at all. intensity of the disease caused by the H1N1 virus.3
The Council of Europe voiced serious concerns that the declara-
tion of a pandemic became possible only after WHO changed
its definition of pandemic influenza. It also expressed misgivings A description versus a definition
over WHO’s decision to withhold publication of the names of
Harvey Fineberg, chairman of a WHO-appointed International
its H1N1 advisory Emergency Committee.3 WHO, however,
Health Regulations (IHR) Review Committee that evaluated
denied having changed any definitions and defended the scien-
WHO’s response to H1N1 influenza, identified the definition
tific validity of its decisions, citing “numerous safeguards” for
of pandemic influenza as a “critical element of our review”.8 In
handling potential conflicts of interest.5
a draft report released in March, the committee faulted WHO
At stake in this debate are the public trust in health officials for “inadequately dispelling confusion about the definition of
and our collective capacity to respond effectively to future disease a pandemic” and noted WHO’s “reluctance to acknowledge its
threats. Understanding this controversy entails acknowledging part in allowing misunderstanding”9 of the web page alteration,
that both parties are partially correct, and to resolve it we must which WHO has characterized as a change in the “description”
re-evaluate how emerging threats should be defined in a world but not in the “definition” of pandemic influenza. “It’s not a defini-
where the simple act of labelling a disease has enormous social, tion, but we recognize that it could be taken as such … It was the
economic and political implications. fault of ours, confusing descriptions and definitions”,10 a WHO

a
Program in History, Anthropology, Science, Technology and Society, Massachusetts Institute of Technology, 77 Massachusetts Avenue (E51-070), Cambridge, MA, 02138,
United States of America.
Correspondence to Peter Doshi (e-mail: [email protected]).
(Submitted: 13 January 2011 – Revised version received: 30 March 2011 – Accepted: 31 March 2011 )

532 Bull World Health Organ 2011;89:532–538 | doi:10.2471/BLT.11.086173

 Round table
Peter Doshi Definition of pandemic influenza

Table 1. World Health Organization (WHO) pandemic influenza guidelines, 1999–2009

WHO Contains Contains clear Content

pandemic definition of basis for
influenza pandemic declaring a
guidelines influenza? pandemic?
199917 Unclear (nothing Yes Text most resembling a definition of pandemic influenza: “At unpredictable intervals, however,
presented as a novel influenza viruses emerge with a key surface antigen (the haemagglutinin) of a totally
formal definition) different sub-type from strains circulating the year before. This phenomenon is called “antigenic
shift”. If such viruses have the potential to spread readily from person-to-person, then more
widespread and severe epidemics may occur, usually to a similar extent in every country within
a few months to a year, resulting in a pandemic” (p. 6)
Basis for declaring a pandemic: “The pandemic will be declared when the new virus sub-type
has been shown to cause several outbreaks in at least one country, and to have spread to other
countries, with consistent disease patterns indicating that serious morbidity and mortality is
likely in at least one segment of the population” (p. 14)
200518 No Yes A pandemic will be said to have begun when a newa influenza virus subtype is declared to have
reached Phase 6. Phase 6 is defined as “Increased and sustained transmission in the general
population” (p. 9)
200919 No Yes WHO writes, “Phase 6, the pandemic phase, is characterized by community level outbreaks in
at least one other country in a different [second] WHO region in addition to the criteria defined
in Phase 5. Designation of this phase will indicate that a global pandemic is under way” (p. 26)
Phase 5: “The same identified virus has caused sustained community level outbreaks in at least
two countries in one WHO region” (p. 27)
Phase 4: “Human-to-human transmission of an animal or human-animal influenza reassortant
virus able to sustain community-level outbreaks has been verified” (p. 27)
a
WHO provides a “Definition of new: a subtype that has not circulated in humans for at least several decades and to which the great majority of the human population
therefore lacks immunity” (p. 6).

communications officer declared. Indeed, by WHO can be seen in the guidelines”.5 occurrence.21 This point has received
the Council of Europe was not alone in This was a reference to WHO’s pandemic widespread attention and criticism.3,7,22,23
claiming that the “definition” had been influenza preparedness guidelines, first de- “The phased approach to pandemic
changed.7,11,12 veloped in 1999 and revised in 2005 and alert was introduced by WHO in 1999,”
WHO argues that this phrase – which 2009. However, none of these documents explained WHO Director-General
could be more neutrally referred to as a contains what might reasonably be con- Margaret Chan to the IHR Review Com-
description–definition – had little bear- sidered a formal definition of pandemic mittee, “to allow WHO to gradually
ing on policy responses; a WHO press influenza (Table 1), a fact that may explain increase the level of preparedness and
release states that it was “never part of the why WHO has refrained from offering a alert without inciting undue public alarm.
formal definition of a pandemic” and was quotable definition despite its repeated In reality, it had the opposite effect.”24
never sent to Member States, but simply assurances that “the definition” was never Indeed, WHO’s concern that declaring
appeared in “a document on WHO’s web- changed.5,13,20 The startling and inevitable phase 6 could “cause an unnecessary
site for some months”.13 In actuality, the conclusion is that despite ten years of issu- panic”25 may explain why it momentarily
description–definition was displayed at the ing guidelines for pandemic preparedness, considered adding a severity index to its
top of the WHO Pandemic Preparedness WHO has never formulated a formal phasing system before declaring phase 6.22
home page for over six years and is consis- definition of pandemic influenza. WHO subsequently decided that devel-
tent with the descriptions of pandemic in- What WHO’s pandemic prepared- oping a pandemic severity index was too
fluenza put forth in various WHO policy ness guidelines19 do contain are “pan- complex.23 However, the IHR Review
documents over the years.14–16 However, demic phase” definitions. WHO declared Committee has called on WHO to “de-
while the original description–definition a pandemic on 11 June 2009, after velop and apply measures that can be used
unambiguously describes disease severity determining that the novel reassortant to assess the severity of every influenza
and certainly reflects general assumptions H1N1 virus was causing community- epidemic”, while noting that “assessing
about pandemic influenza before novel level outbreaks in at least two WHO severity does not require altering the
H1N1 emerged, it is unrelated to the cri- regions, in keeping with the definition definition of a pandemic to depend on
teria WHO applied to declare H1N1 of pandemic phase 6. The declaration of anything other than the degree of spread”.9
influenza a pandemic. phase 6 reflected wider global dissemina- WHO’s defence of its decision to
tion of H1N1, not disease severity. But declare H1N1 influenza a pandemic
Definitions of pandemic unlike other numerical scales, such as the because it met “hard to bend”, “clearly
phases, not pandemic Saffir–Simpson Hurricane Wind Scale defined virological and epidemiological
based on five “categories”, WHO’s six- criteria”26 overlooks the fact that these
influenza point pandemic phase determinations criteria changed over time. As Gross
In a press conference, WHO explained do not correlate with clinical severity noted, under WHO’s previous (2005)
that “the formal definitions of pandemics but rather with the likelihood of disease guidelines the 2009 H1N1 virus would

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 Round table
Definition of pandemic influenza Peter Doshi

not have been classified as a pandemic

Fig. 1. Requirements for an influenza pandemic, World Health Organization (WHO) and
influenza virus simply because it was not US Centers for Disease Control and Prevention (CDC)a
a new subtype.27 The 2009 plan, by con-
trast, only required a novel “reassortant”
virus (Table 1). World Health Organization (18 May 2009) US Centers for Disease Control and
Prevention (1 March 2009)
59

Statements from WHO such as “Is

this a real pandemic. Here the answer is
very clear: yes”5 suggest that pandemics
are something inherently natural and
obvious, out there in the world and not
the subject of human deliberation, debate
and changing classificatory schemes. But
what would and would not be declared a
pandemic depends on a host of arbitrary
factors such as who is doing the declaring
and the criteria applied to make such a
declaration.

Bridging the gap

Had the novel 2009 H1N1 virus caused
exceptionally severe disease, the exten-
sive preparations and planning in recent
years would have surely put us in a better
position to respond to such a crisis, and
decision-making at WHO would not
have come under intense scrutiny.28 But in
the case of H1N1, governments mounted
extraordinary and costly responses to a
These are slides from WHO35 and CDC36 training materials posted to the WHO web site (http://influenzatraining.
what turned out to be mostly ordinary org). The dates indicate when the materials were last updated.
disease.29,30 This resulted in much scrutiny
and controversy over the decision-making scenarios”32 yielded numbers that were “novel” virus such as H1N1 could meet
process. As future policy responses to four to 30 times greater than the esti- current phase 6 criteria highlights the
emerging infectious diseases will not suc- mated number of deaths from seasonal shortcomings of virological assumptions
ceed without the trust and understanding influenza.33 Also, over the last five years and their central role in defining pan-
of the public, officials must revise the way public health experts and policy-makers demic response measures. The enduring
they think about and characterize emerg- have helped consolidate the idea that a belief is that highly transmissible novel
ing diseases. pandemic is of necessity a catastrophe influenza viruses can be expected to cause
A first step is to openly acknowledge through repeated mention of the severe serious disease and even death because
past failures in risk assessment. The de- 1918 pandemic “in order to rouse gov- the population lacks immunity against
scription–definition of pandemic influenza ernments and the public”.34 Descriptions them.49 However, this view is challenged
that was on WHO’s web site for so long, of H5N1 as a pandemic candidate virus by the recent experience with H1N1 and
unchallenged and unchanged for years, is because it had met all the “requirements” other influenza pandemics.37,50–52 During
perhaps the most striking illustration that only reinforced the message that a serious the 2009 H1N1 outbreak, relatively few
expert institutions assumed pandemics outbreak was inevitable (Fig. 1). The focus elderly people got sick,51,53,54 despite the
to be, in their basic nature, catastrophic
on 1918 and H5N1 came at the cost of widespread circulation of the so-called
events. (According to the IHR Review
preparing for possible future outbreaks novel virus, and when they did, the symp-
Committee, the description–definition
similar to the 1957 and 1968 pandemics. toms were mild in most cases.
was “understandable in the context of
expectations about [avian influenza] These outbreaks, in contrast to the one Virus-centric thinking is also at the
H5N1”,9 but its appearance dates back to in 1918, were similar to seasonal influ- bottom of the current practice of dichoto-
at least early 2003, when only 18 human enza and sometimes milder;37–39 indeed, mizing influenza into “pandemic” and
cases of H5N1 were known.)6 But it is historical descriptions of events in 1957 “interpandemic” or “seasonal” influenza
by no means the only example of false as- and 1968 have been mixed, a fact that on the basis of genetic mutations in the
sumptions. A 2005 WHO preparedness highlights the lack of standardized mea- virus. This approach, however, ignores
document titled Ten things you need to sures of severity (Table 2). Preparations the fact that the severity and impact of
know about pandemic influenza31 stated for future outbreaks must take stock of all epidemics, whether caused by influenza
that “large numbers of deaths will occur” the evidence, not just the most alarming. viruses or other pathogens, occur along a
and “economic and social disruption Second, it is time to re-examine spectrum and not in catastrophic versus
will be great”. Statistical projections of assumptions driven by virus-centric non-catastrophic proportions. We need
future pandemic mortality varied widely, thinking. The fact that the spread of responses that are calibrated to the na-
but even the self-described “best case overwhelmingly mild 47 disease by a ture of the threat rather than driven by

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 Round table
Peter Doshi Definition of pandemic influenza

these rigid categories.11 The IHR Review

Table 2. Descriptions of influenza outbreaksa that have carried the “pandemic” label
Committee has called for simplifying the
pandemic phase structure and for plans
Year Virus Nickname Descriptions
that “emphasize a risk-based approach to
enable a more flexible response to differ- 1918 H1N1 Spanish flu “devastating pandemic” (US CDC)40
ent scenarios”.9 However, implementing “severe” (US CDC)41
this will remain difficult as long as health “exceptional” (WHO)42
officials feel compelled to “err on the 1957 H2N2 Asian flu “comparatively mild” (WHO)42
side of safety”9 and respond to any novel “substantial pandemic” (WHO)17
influenza virus as if it were potentially a “severe” (US CDC)41
worst case scenario. We therefore need “moderate” (US HHS)43
evidence-based ways to address hypo- 1968 H3N2 Hong Kong flu “moderate” (US CDC)41
thetical scenarios of non-zero probability, “huge economic and social disruption” (UK DoH)44
such as the fear – based on a very partial “mild” (WHO)45
reading of history55 – that novel influenza “substantial pandemic” (WHO)17
pathogens acquire increased virulence “Few people who lived through it even knew it occurred.”
during successive “waves” of infection. (John Barry)46
Virus-centric thinking may heavily 1977 H1N1 Russian flu “mild” (US CDC)41
influence pandemic influenza planning “benign pandemic” (WHO)17
because of the considerable weight of ex- 2009 H1N1 Swine flu “moderate” (WHO)5,47
pert opinion. Bonneux and Van Damme “largely reassuring clinical picture” (WHO)48
have argued that disease experts are not
US CDC, United States Centers for Disease Control and Prevention; UK DoH, United Kingdom Department of
necessarily competent to judge a disease’s
Health; US HHS, United States Department of Health and Human Services; WHO, World Health Organization.
relative importance against competing a
Whether it is called an outbreak, epidemic, or pandemic, influenza has a cyclic propensity to capture the
health priorities, and “final evidence- world’s attention and to generate large public health responses. However, with the exception of the 1918
based policy advice should be drafted by pandemic, which all agree was catastrophically severe, the impact of more recent outbreaks carrying the
independent scientists trained in evalua- “pandemic” label is difficult to gauge, as their divergent descriptions suggest.
tion and priority setting”.56 This advice is
consistent with the views of Neustadt and procedures for the appointment of mem- regardless of the pathogen that causes
Fineberg, who noted over three decades bers of expert committees”.9 Since the them, planning for hypothetical “worst
ago in their review of the 1976 swine flu 1980s, “partnerships” between industry case” scenarios has value. But such sce-
affair in the United States of America that and academia have grown increasingly narios are rare and, when they do occur,
“panels tend toward ‘group think’ and close.58 Today, for example, both govern- few people will require convincing that
over-selling, tendencies nurtured by long- ment officials and academic influenza urgent action is needed. Indeed, if we
standing interchanges and intimacy, as in scientists belong to the Neuraminidase do face the threat of widespread disease
the influenza fraternity. Other competent Inhibitor Susceptibility Network, a group causing severe symptoms, the definition
scientists, who do not share their group funded by GlaxoSmithKline and Roche.59 of pandemic influenza will likely become
identity or vested interests, should be able Much work is needed to ensure that deci- moot. ■
to appraise the scientific logic applied to sions are not unwittingly influenced by
available evidence.”57 However, the IHR industrial interests. Acknowledgements
Review Committee’s draft report, issued Finally, we must remember the I am grateful to Yuko Hara, Peter Grau-
in March 2011, is less demanding. It calls purpose of “pandemic preparedness”, mann and Tom Jefferson for their percep-
for an “appropriate spectrum of exper- which was fundamentally predicated on tive observations and comments. I also
tise” to advise WHO’s Director-General the assumption that pandemic influenza wish to thank the Hugh Hampton Young
but fails to specify whether this should requires a different policy response than Memorial Fellowship committee at MIT
include non-influenza experts such as gen- does annual, seasonal influenza. The for their generous support of my research.
eral epidemiologists, general practitioners “pandemic” label must of necessity carry
and health economists.9 a notion of severity, for otherwise the Competing interests: None declared. I
Third, we must come to broader rationale behind the original policy of would, however, like to acknowledge fi-
agreement about acceptable sources of having “pandemic plans” distinct from nancial support from the UK National In-
expert advice. While the IHR Review ongoing public health programmes would stitute for Health Research Health Tech-
Committee “found no evidence of mal- be called into question. Insofar as these nology Assessment programme for work
feasance”, it urged WHO to “clarify its plans allow us to effectively respond to on a Cochrane review of neuraminidase
standards and adopt more transparent the spread of severe infectious diseases, inhibitors (http://www.hta.ac.uk/2352).

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Definition of pandemic influenza Peter Doshi

‫ملخص‬
‫التعريف املراوغ لجائحة األنفلونزا‬
‫تغي تعريفها لجائحة األنفلونزا‬
ّ‫إن منظمة الصحة العاملية مل تقدم عىل ر‬ ‫ حول‬،‫ والسيام يف أوروبا‬،‫ظل جدل واسع النطاق يدور طوال العام املنرصم‬
‫ ومع‬،‫لسبب بسيط وهو أنها مل تع ّرف رسمياً عىل اإلطالق جائحة األنفلونزا‬ ‫تغي من تعريفها لجائحة‬ ّ‫غيت أم مل ر‬
ّ‫ما إذا كانت منظمة الصحة العاملية قد ر‬
‫أن منظمة الصحة العاملية قد رشعت يف العديد من التوصيفات لجائحة‬ ‫ البعض رأى‬.‫ الجديد‬H1N1 ‫ بعد اكتشاف فريوس‬،2009 ‫األنفلونزا يف عام‬
‫ إال أنها مل تستقر رسمياً حتى اآلن عىل تعريف ومعايري إلعالن‬،‫األنفلونزا‬ ‫ بل أنه هدف إىل متهيد الطريق‬،‫أن التغيري مل يقترص عىل التعريف وحسب‬
‫ وفقاً ملا هو مستمد من تعريفات “مرحلة‬H1N1 ‫الجائحة الناجمة عن فريوس‬ ‫ ويدّعي البعض اآلخر أن التعريف مل يتغري عىل اإلطالق‬.‫لإلعالن عن الجائحة‬
‫ والحقيقة أنه مع مرور‬.”‫ وليس وفقاً لتعريف “جائحة األنفلونزا‬،”‫الجائحة‬ ‫ وقد أعاق هذا االستقطاب يف‬.‫وأن هذا الزعم ليس له أي أساس من الصحة‬
‫عرش سنوات عىل أنشطة التأهب للجائحة مل يصاغ حتى اآلن تعريف رسمي‬ ‫ بجانب مشاعر‬،‫ هذا التأزم‬.‫اآلراء قدرتنا عىل الوصول إىل استنتاجات هامة‬
‫ وعىل‬.‫مام يكشف الفرضيات الضمنية الهامة لطبيعة هذا املرض املعدي‬ ‫القلق املحيطة باحتامل وجود تضارب يف املصالح والشكوك حول عدم التوازن‬
‫ يستدعي القصور يف األساليب “املتمركزة عىل الفريوس” املزيد‬،‫نحو خاص‬ ‫ قد أدى إىل إضعاف ثقة الناس‬،H1N1 ‫النسبي يف االستجابة لفاشية أنفلونزا‬
‫من االهتامم وينبغي إطالع الجهود املتواصلة عىل “الدروس املستفادة” التي‬ ‫يف املسؤولني الصحيني وإضعاف قدرتنا الجامعية عىل االستجابة الف ّعالة‬
.‫سرتشد إىل سبل االستجابة لفاشيات األمراض املعدية الجديدة يف املستقبل‬ .‫لتهديدات األمراض يف املستقبل‬

摘要
流感大流行难以捉摸的定义
确定了新型甲型H1N1流感之后,关于世界卫生组织(WHO) 界卫生组织对大流行性流感提出了很多描述,但是其从未
是否于2009年改变了其对流感大流行的定义,在过去的一 确立其正式定义,而因甲型H1N1流感病毒引起的大规模流
年中有着相当大的争议，特别是在欧洲,。一些人认为不 行病的宣布标准是源自“流行病阶段”的定义,而不是“大
仅仅是定义发生了改变,而且这种改变为宣布流感大流行铺 流行性流感”的定义。尽管为大规模流行性疾病已经做了
平了道路。其他人则认为定义从未发生改谈,并且认为该主 十年的准备工作,但是尚未制定大流行性流感的正式定义,这
张是毫无根据的。这些两极化观点妨碍了我们得出重要结 一事实揭示了关于这种传染病性质的重要基本假设。特别
论的判断。这种僵局以及对潜在利益冲突的忧虑和对甲型 是“以病毒为中心”的方法的局限性值得进一步关注,并且
H1N1流感暴发反应程度的疑惑已经破坏了公众对卫生官 现行研究工作应“吸取教训”,这将引导应对未来新型传染
员的信任和我们有效应对未来疾病威胁的能力。 性疾病暴发。
世界卫生组织并没有改变其对大流行性流感的定义,原
因很简单,那就是其从未正式定义大流行性流感。尽管世

Résumé
L’insaisissable définition de la grippe pandémique
Depuis l’an dernier, il existe une importante controverse, en particulier en L’OMS n’a pas modifié sa définition de la grippe pandémique pour la
Europe: l’Organisation mondiale de la Santé (OMS) a-t-elle changé ou non simple raison qu’elle ne l’a jamais définie de manière officielle. Alors que
sa définition de la grippe pandémique en 2009, après l’identification de l’OMS a proposé de nombreuses descriptions de la grippe pandémique,
la grippe H1N1 originale? Certains ont soutenu que non seulement cette elle n’a jamais élaboré une définition formelle. De plus, les critères de
définition a été modifiée, mais qu’elle l’a été dans le but de préparer la déclaration d’une pandémie causée par le virus H1N1 ont leur origine
déclaration d’une pandémie. D’autres ont expliqué que la définition n’a dans les définitions de la «phase pandémique», et non dans une définition
jamais été changée et que cette allégation est dénuée de tout fondement. de la «grippe pandémique». Le fait que, malgré dix années d’activités
Ces vues polarisées ont gêné notre capacité à tirer des conclusions de préparation à une pandémie, aucune définition officielle de la grippe
importantes. Cette impasse, associée aux préoccupations sur les conflits pandémique n’ait été formulée révèle des hypothèses sous-jacentes
d’intérêts potentiels et aux doutes sur la proportionnalité de la réponse importantes sur la nature de cette maladie infectieuse. Les limitations
à l’apparition de la grippe H1N1, a sapé la confiance publique envers des approches «axées sur les virus» méritent en particulier une plus
les autorités sanitaires et envers notre capacité collective à répondre de grande attention et doivent contribuer aux efforts incessants pour «tirer
manière efficace aux menaces des maladies futures. des leçons» qui guideront la réponse aux apparitions futures de nouvelles
maladies infectieuses.

Резюме
Неуловимое определение пандемического гриппа
В прошлом году велись серьезные споры, особенно в Другие заявляли, что определение никогда не менялось и
Европе, о том, не изменила ли Всемирная организация что это утверждение абсолютно беспочвенно. Подобная
здравоохранения (ВОЗ) свое определение пандемического поляризация мнений мешает нам прийти к важным
гриппа в 2009 году, после того как был обнаружен выводам. Этот тупик, сочетающийся с озабоченностью по
новый вирус гриппа H1N1. Некоторые утверждали, что поводу потенциального конфликта интересов и сомнениями
определение было не просто изменено, но изменено в пропорциональности реакции на вспышку гриппа H1N1,
намеренно, чтобы облегчить объявление пандемии. подрывает доверие общественности к высокопоставленным

536 Bull World Health Organ 2011;89:532–538 | doi:10.2471/BLT.11.086173

 Round table
Peter Doshi Definition of pandemic influenza

деятелям системы здравоохранения и ослабляет нашу обеспечению готовности к пандемическому гриппу

коллективную способность эффективно реагировать на длились десять лет, какого-либо формального определения
угрозы заболеваний в будущем. пандемического гриппа не было сформулировано, что
ВОЗ никогда не меняла определение пандемического свидетельствует о важных исходных предположениях
гриппа по той простой причине, что она никогда не давала относительно характера этого инфекционного заболевания.
такого определения. Хотя ВОЗ предлагала множество В частности, ограниченность «вирусоцентрических»
описаний пандемического гриппа, она так и не выработала подходов заслуживает дальнейшего внимания и должна
его формального определения, а критерии объявления определять продолжающиеся усилия по «извлечению
пандемии, вызванной вирусом H1N1, вытекали из уроков», которые будут формировать реакцию на вспышки
определений «пандемической фазы», а не из определения новых инфекционных болезней в будущем.
«пандемического гриппа». Хотя мероприятия по

Resumen
La evasiva definición de la gripe pandémica
Durante el pasado año, fundamentalmente en Europa, se generó una La OMS no cambió su definición de gripe pandémica por el simple
considerable polémica sobre si la Organización Mundial de la Salud (OMS) motivo de que nunca antes había definido formalmente el concepto de
habría cambiado su definición de gripe pandémica en el año 2009, tras gripe pandémica. Si bien la OMS ha propuesto numerosas descripciones
la identificación de la nueva gripe H1N1. Algunos argumentan que no de gripe pandémica, nunca estableció una definición formal y los
solo se cambió la definición, sino que se hizo para despejar el camino criterios para la declaración de una pandemia provocada por el virus
hacia la declaración de una pandemia. Otros aseguran que la definición H1N1 procedían de las definiciones de «fase de alerta pandémica», no
nunca se cambió y que esta alegación está completamente infundada. de una definición de «gripe pandémica». El hecho de no contar con una
Estos puntos de vista tan opuestos han dificultado nuestra capacidad definición formal de gripe pandémica, a pesar del bagaje de los diez años
para extraer conclusiones relevantes. Este callejón sin salida, unido a las de actividades de preparación contra las pandemias, revela importantes
preocupaciones sobre los posibles conflictos de intereses y las dudas suposiciones subyacentes sobre la naturaleza de esta enfermedad
sobre la proporcionalidad de la respuesta al brote de la gripe H1N1, ha infecciosa. En particular, las limitaciones de los enfoques «centrados
menoscabado la confianza de la población en los responsables de la salud en el virus» reclaman una mayor atención y se debe informar sobre los
y en nuestra capacidad colectiva para responder con eficacia a futuras esfuerzos que se realicen para «aprender las lecciones» que dirijan nuestra
amenazas de este tipo. respuesta ante los futuros brotes de nuevas enfermedades infecciosas.

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