Editorial
Pandemic influenza—(some) reasons to be cheerful?
There was no fanfare to accompany WHO’s declaration
on Aug 10 that the world was entering a “post-pandemic
period” and that influenza A H1N1 had “largely run its
course”. But the aftershocks of the pandemic might last
for a long time, so this announcement should herald the
start of a period of reflection.
From the first cases, in Mexico, in March, 2009, to
identification of the culprit virus took WHO’s global
influenza surveillance network just 6 weeks. Then, with
only oseltamivir to protect the world’s population, the
cogs of the influenza vaccine production mechanism
whirred into action. Normally competitive groups
collaborated, and countries around the world shared data
on virus strains, despite fears that many would not do so
without a binding agreement guaranteeing vaccines in
return for data. Once a suitable seed strain was grown,
drug companies started to make a useable vaccine. From
virus identification to vaccine approval by the US Food
and Drug Administration took 6 months. So far, so good.
But from here on, chinks in the pandemic preparedness
armour started to appear.
Vaccine production could have been quicker. Newer
methods that use cell culture, or baculovirus expression
systems, could be much more responsive than the egg-
based method that is currently used. Until recently,
financial considerations have meant that these newer
techniques have not received the deserved attention
from industry. Vaccine production was also limited to a
handful of more developed countries, contributing to the
familiar division between the haves and have-nots. WHO
and the UN Secretary General worked tirelessly to ensure
vaccine delivery to low-income and middle-income
countries, but from the outset were dogged by a lack of
vaccine-producing capacity, recalcitrant politicians, and
inadequate plans. Even if vaccines reached developing
countries, a lack of infrastructure hampered deployment.
There was a stark contrast between countries rich enough
to stockpile vaccines, and others (eg, Laos and Cambodia)
who for many months had none.
Ironically, people in high-income countries used their
vaccine stockpiles reluctantly. Around 80% of people in
the UK chose not to be vaccinated, many because they
doubted they were at serious risk. They were correct,
but we know this only after the fact. Despite the fairly
mild course in most infected individuals, more than
www.thelancet.com Vol 376 August 21, 2010
18 449 people died and hundreds of thousands were
severely affected around the world. It is a testament to
global health-care systems that many were successfully
treated. However, the pandemic largely caught the
research community unawares. Although anecdotes and
observational data have been gathered, few patients
were entered into randomised trials, and thus solid data
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to inform treatment decisions for future pandemics
are lacking. Where they existed, countrywide plans for
handling a pandemic were predicated on an outbreak of
severe H5N1 influenza, but were too draconian for the
milder H1N1 strain, while many countries carried on with
business as usual.
Questions are rightly being asked about the influence
of the drug industry on WHO’s decision-making process,
but to focus on this alone would be foolish. Now is not
the time to apportion blame, but to ask: how can we do
better next time? First, we need to be better prepared.
There needs to be global investment in responsive
vaccine production systems, which allow production to
track demand. Plans are also required to ensure equitable
distribution of vaccines and antiviral drugs. Developed
countries should not be able to stockpile unused vaccines,
while people in the developing world go without. Planning
for equitable worldwide vaccination will require the
development of a political framework to ensure adequate
funding, procurement agreements, and worldwide
distribution strategies well before the next outbreak.
Such plans will help to ensure that poorer countries have
enough incentives to share information about emerging
virus strains, and do not feel that they are giving their
wealthier counterparts information, for no benefit.
Preparedness plans also need to have the flexibility to be
able to cope with a range of pandemic severity.
Second, we need systems in place to maximise learning.
Protocols and approvals should be ready for randomised
trials of treatment strategies; these could then begin
recruiting as soon as an outbreak occurs. But finally,
and perhaps most importantly, we need to rebuild a
relationship of trust with the public. The disparity between
predicted and actual severity of this pandemic has severely
For more on Patient-oriented
dented experts’ credibility, so now experts need to use all pandemic influenza research
methods at their disposal to engage the public. The best see Lancet 2009; 373: 2085–86.
For more on Confirmation of
laid plans will come to nothing if people have lost faith in influenza infection see Lancet
the information and interventions available. ■ The Lancet 2008; 372: 696–97.
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