To guard against thousands of possible deaths, the Government set aside €80 million for swine flu vaccines, only a fraction of which were used. Was it an over-reaction, or a Catch-22 situation?
QUIETLY, AND with barely a flicker of media interest, the last weekly briefing note on the swine flu pandemic was released a week ago. There wasn’t much to excite even the most news-starved of reporters. Influenza activity was low. There had been no confirmed reports of swine flu. The vaccination campaign against the virus had officially drawn to a close.
This was in stark contrast to a few months earlier. Special weekly press conferences at Government Buildings were packed with media to hear top-ranking health officials talk about the public health threat facing the State.
Somehow, more than €80 million was scrambled together by health authorities to buy millions of vaccines, as well as anti-virals, masks and goggles. The national influenza pandemic plan was dusted down, along with the possibility that schools, universities and workplaces could be closed down as a protective measure. Most measures avoided creating a sense of panic, but it didn’t always work. The media stoked fears, speculating that special morgues would be set aside and that the Army could be called in. A distinguished UK virologist even raised the possibility that swine flu could travel south and mix with bird flu to create “Armageddon flu”.
In the end, the consequences weren’t nearly as bad as was feared. The H1N1 virus turned out to be a relatively mild strain compared to the more deadly avian flu (which killed one-third of those infected). About 5 per cent of the Irish population contracted the H1N1 virus, and 24 people died. Health authorities now find themselves saddled with two-thirds of the swine flu vaccines unused.
Given that in a typical flu season around 300 to 400 people die of flu-related illnesses, many are beginning to question whether health authorities over-reacted to the scale of the problem. To add into the mix, sceptics such as Wolfgang Wodarg, former chairman of the health sub-committee at the Council of Europe, say the swine flu outbreak was a “false pandemic” driven by drug companies which stood to make billions from a worldwide scare.
The biggest worry facing some health experts is that public trust may have been undermined – so the next time a pandemic disease hits, people may not take it seriously, a situation that could put the whole population at risk. Dr Kevin Kelleher, head of health protection at the Health Service Executive, played a key role in co-ordinating the State’s response to the swine flu threat.
“I don’t think we over-reacted,” says Dr Kelleher. “If you were to speak to people who had the swine flu, or to the families of those who died, you would get a very different picture. Maybe our reaction reduced the scale of the people affected . . . People were given advice, vaccinations were provided. I’d be happy to debate our reaction with anyone.”
One issue is the national pandemic influenza plan, a detailed guide drawn up for health authorities three years ago. But this was written with the avian flu in mind, which is far more severe, and envisages a scenario where the first wave of a pandemic could result in anything up to 50,000 deaths.
“Yes, the swine flu wasn’t as severe as we might have feared, but it still had a major impact,” says Dr Kelleher. “We are looking at lessons learned, but the plan was adapted as we went on to the emerging situation.” One key adaptation, for example, was that hospitals continued to operate normally; whereas the plan envisages health services being forced to take drastic action to deal with a pandemic.
Prof Patrick Wall, associate professor of public health at UCD, takes a similar view, and says the health authorities got it right.
When the virus first emerged last April, he was quick to dampen any sense of panic. He said the swine flu appeared to be similar to ordinary flu and warned against over-reacting.
“Looking back, I suppose I was half right and half wrong,” Prof Wall says. “It wasn’t Armageddon. But it wasn’t an ordinary version of the flu, either. It affected young people and pregnant women disproportionately. It was very serious for those vulnerable groups.” There was always the possibility that a second wave of the flu could have been much more life-threatening, he says.
“As far as world health agencies are concerned, they were damned if they did and damned if they didn’t [declare] a pandemic. I thought Tony Holohan [chief medical officer at the Department of Health] put it well last year. While the flu appeared to be mild, he said there were no grounds for complacency. That was good advice.”
Ultimately, Ireland was guided by the World Health Organisation (WHO) in how it responded. Its emergency committee made a crucial decision on June 11th, declaring that an influenza pandemic had broken out, for the first time in just over 40 years.
As the WHO’s director of global outbreak alert and response network, Dr Mike Ryan played a key role in shaping the organisation’s response. “I feel very comfortable that the right calls were made at the right time,” says Dr Ryan, originally from Co Sligo and now based in Geneva. “We live in a world of risk management. And this was a new strain of virus which was spreading like wildfire around the world and to which humans had no immunity. People were dying in intensive care, pregnant women were dying, under-twos were dying and the virus was adapting.” A pandemic, or “phase six” on the WHO’s warning system, occurs when a new virus is spreading uncontrollably in several regions of the world.
While the organisation’s previous definition referred to a virus that created a “high mortality rate”, this was left out of a more recent and revised definition.
On its website, the answer to the question “What is a pandemic?” included mention of “an enormous number of deaths and cases of the disease” – until May 4th, 2009.
That was when a CNN reporter pointed out the discrepancy between this description and the generally mild course of the swine flu. The language was quickly removed.
Some sceptics say a group with strong connections in Geneva had a strong interest in phase six being declared: the drugs industry. Once a pandemic was declared, sleeping contracts to supply millions of vaccines to dozens of governments around the world would automatically come into force.
"Sometimes you get the feeling that there is a whole industry almost waiting for a pandemic to occur," Tom Jefferson of the Cochrane Collaboration, an international non-profit organisation, told German news magazine Der Spiegelrecently. "And all it took was one of these influenza viruses to mutate to start the machine grinding."
Dr Ryan of the WHO rejects any suggestion that the pharmaceutical industry pressurised the organisation into declaring a pandemic. “It beggars belief that we would risk the integrity of our massive health agenda globally by helping companies to make short-term profits. It’s simply not in our interest to do so,” he says.
It is almost impossible to know the severity of a pandemic in its early stages, he adds, given the ability of flu strains to mutate quickly and impact differently among diverse populations.
Ireland was one of many countries that had signed agreements with vaccine manufacturers to supply pandemic jabs. It paid some €6 million in “hello money” to vaccine makers – just to secure access to supplies when they became available.
In addition, it ordered 7.7 million vaccines, enough for two doses for each member of the population at a total cost of close to €80 million. This included equal batches of Pandemrix, a vaccine made by GlaxoSmithKline, and Celvapan, made by Baxter.
Months later, however, it emerged that a shot of Pandemrix was sufficient for both children and adults, except those with weakened immune systems.
As a result, the Government renegotiated its contract with Baxter, saying it would not take up close to four million doses of its vaccine, saving up to €35 million in the process. However, it is still left with two-thirds of the vaccine that arrived in the country. It is in talks with GlaxoSmithKline over how to honour a contract worth between €5 million and €15 million. Most developed countries face a similar problem, but not everyone.
Poland’s government, which chose not to buy the vaccine, feels vindicated by its stance. While opposition parties grumbled, its health minister, Ewa Kopacz, told the parliament: “Is it my duty to sign agreements that are in the interest of Poles, or in the interest of the pharmaceutical companies?”.
So, what lessons can be learned from the swine flu pandemic? The WHO, for its part, has announced that an external panel will review the decisions it took over the handling of swine flu as part of a process which begins on Monday.
John MacKenzie, the chair of the organisation’s emergency committee, a group of 15 health experts from around the world, has already suggested that the WHO’s definition of a pandemic may need to be fine-tuned to include severity.
Dr Ryan feels that while its response was speedy and effective, there could be room for improvement on aspects of communications. “Was there unnecessary confusion in this pandemic versus the seriousness of something like H5N1 [avian flu]? That’s something that will be looked at.” For Prof Patrick Wall, the allegations against the WHO are serious and need to be addressed – if only to ease the public concerns.
“These allegations need to be banged on the head and sorted out, ” he says. “An inquiry might help us learn lessons from this.”
SWINE FLU IN NUMBERS
22 millionThe cost in euro of buying and administering vaccines in Ireland
1.9million Number of unused doses of pandemic vaccines in Ireland
1.1million Number of doses of pandemic vaccine administered in Ireland
16,931Number of deaths worldwide linked to swine flu
4,584Number of confirmed cases of swine flu notified in Ireland
25%The proportion of the population that received the vaccine
24Number of deaths in Ireland linked to swine flu
