WHO and the pandemic flu “conspiracies”

This is the original response to Nature's Declan Butler answering his
queries prior to the publication of his story "Flu experts rebut conflict
claims", which was published online on 8 June 2010 (Nature 465, 672-673
(2010)). It was sent at 5.10pm with a request for a response by 10am the
following day.

Question 1. The BMJ report says: "A key question will be whether the
pharmaceutical companies, which had invested around $4bn in developing the
swine flu vaccine, had supporters inside the emergency committee, who then
put pressure on WHO to declare a pandemic. It was the declaring of the
pandemic that triggered the contracts."

Although the WHO's brief includes recommending when large-scale
pandemic vaccine production should start, national governments, in
particular those of rich countries, were hardly waiting on WHO's official
nod before pushing ahead themselves with their own pandemic responses.
Weeks before WHO declared a pandemic, many countries including the United
Kingdom, France, Belgium, Finland, Canada, The Netherlands, and
Switzerland, had already placed large orders of H1N1 vaccine, the US, for
example, ordered $649 million of pandemic H1N1 influenza vaccine antigen
and $283 million of adjuvant on May 22, 2009. ?So it wasn't the declaring
of the pandemic that triggered the contracts. Comments.

RESPONSE: You are absolutely right. But WHO's brief includes saying
when pandemic production should be begin and it's fair to say questions
are being asked about what influence companies had on WHO by member
countries of the Council of Europe, which represents 47 countries. (See
CoE report)

Sleeping contracts were in place in Italy and Germany at least. Both
contracts make reference to previous agreements and the German contract
was signed in 2007.
In May 2009 at the World Health Assembly- before the pandemic was declared
- several governments urged for caution in moving to phase 6 because it
would trigger unnecessary costly and risky actions even though the virus
seems mild so far. The UK was one of them and received backing from other
countries. They commented on the fact that the definition on a pandemic
was being focused on geographical spread rather than severity - something
they were not entirely happy with.
At the same meeting, it was stated that declaring phase 6 should be
closely tied to the issue of when to switch from seasonal flu production
to pandemic flu vaccines.

We are not categorically stating that there was influence. It might
be that nothing comes to bear. We'll know when WHO issues their report and
opens up their decision making processes for due consideration.

Question 2. WHO also made no recommendations as to the quantities of
vaccine that should be ordered, surely, which was a national decision, and
off the top of my head, if I remember right, it discouraged immediate
whole population vaccination strategies given vaccine shortages at the
start so that more vaccine would be available to high risk groups in more
countries? Comments?

RESPONSE: This is beyond the scope of our feature and we don't have
much to add. However, the attached Kieny pdf may be of assistance. It
states:
?"In 2006, the WHO developed a global pandemic influenza vaccine action
plan [9] (GAP) to enable production of enough vaccine to immunize the
world's population (6.7 billion people) within 6 months after a pandemic
virus vaccine candidate becomes available." (See attached Marie Paule
Kieny and Keiji Fukuda, "The pandemic influenza vaccine challenge,"
Vaccine 26, no. Supplement 4 (September 12, 2008): D3-D4.

Question 3. WHO has also said it will make public the names, and any
competing interests, of the emergency committee once the pandemic is
declared over. Were you aware of this, and does this change your take in
any way?

RESPONSE: We certainly are and have been aware of this.? Such post-facto disclosure does not allow anyone to evaluate any potential conflicts
of interest at the time when such issues are material to decisions being
made.

One of the points was that there is an inconsistent approach to
transparency. Other committees were named. As David Salisbury said, the
secrecy had put his committee-which was named- under extra scrutiny. And,
as he put it, this was pandemic flu and not bioterrorism. It's the secrecy
of this committee that, in part, led to various inquiries and questions
(rightly or wrongly) being asked.

Deliberations about key decisions were not made public eg changing the
definition of a pandemic.

Governments do rely on WHO for their advice and they need to set a
high standard. With this level of authority there needs to be
accountability.

It's easy to criticise in hindsight- and if the pandemic had had a
higher mortality rate- there's no doubt we'd be asking different
questions. But we do think it's worth considering if this was the right
approach to take.

Question 4. One researcher says that the implication of the two
reports is that if particular scientists involved in pandemic planning had
not had any relationship with drug companies, they would have offered
different advice. "This is a pretty serious charge," he says, and one that
neither the BMJ or PACE reports substantiate.
Comments.

RESPONSE: This point really does underscore the importance of
conflict of interest policies and what COIs really are. We think this is
the researcher's reading into it - not necessarily ours - and therefore of
course it is not something our feature would substantiate as it does not
address this specific point. It is speculation.

If we had made the charge about them giving different advice had they
not had financial links we would have put that allegation to the WHO and
the scientists involved.

We were pointing out that perhaps there was some basis for concerns
that WHO had used experts with industry ties and hadn't been transparent
about it. This is in contrast to medical journals-which are not advising
governments what to do- that have open COI statements.
We have copied at the end of this response the WHO's own position on what
constitutes a COI. It is also worth bearing in mind that when assessing
COIs one test the WHO uses is the following (DECLARATION OF INTERESTS FOR
WHO EXPERTS Explanation sheet for the WHO Secretariat):

As an aide in performing the assessment under (c) on whether participation
of the expert in the meeting or work with public disclosure of the
expert's declared interest is possible, one should assess the situation
through the eyes of a hypothetical "person on the street".? If it is felt
that there is a reasonable likelihood that such a person might conclude
the proceedings or work as a whole were tainted, unfair or otherwise
influenced by this expert's interest in the outcome, then the expert's
involvement should be limited as described in (c)(ii) or (iii) above.
?
If the answer is (b), review the declared interest through the same eyes
of a hypothetical "person on the street".? If it is felt that there is a
reasonable likelihood that such a person might conclude that the expert
concerned is biased, then proceed as in the case for (c) above to see
whether the expert's participation is still possible or must be excluded
in whole or in part.

Question 5. The 2004 document was based on input from an
international panel of 22 scientists and public health officials. How do
you think this small minority could influence such a large group?

RESPONSE: We focused on the primary authors of the annexes, who
clearly had a major role in developing the guidelines.? This again is
about transparency of decision making-not necessarily about influence. If
key advisers have a financial relationship with those pharmaceutical
companies shouldn't that be made transparent? Also, WHO has very clear
guidance on using people with industry ties in drafting guidelines (see
feature for details). All we were trying to find out is if they followed
their own guidance.

Much of the spotlight on WHO could have been avoided if it was clear
they followed their own guidance. And, more importantly, were transparent.
Moreover, we cannot categorically state that all other 22 scientists did
not have financial ties. WHO has not put this information into the public
domain. We do also know that representatives from Roche and Aventis were
at the 2002 meeting on which the guidelines were based.

Question 6. And just to clarify re competing interests; your main
concern is that these weren't included in WHO pandemic planning documents,
although they were declared to WHO, as well as in other places. Is that
correct? In passing, were any of the competing interests so financially
large -- examples? -- as to clearly constitute conflicts of interest?

RESPONSE: Our main point was to highlight the WHO's handling of COIs
in pandemic planning. We simply wanted to know what WHO considers what a
COI to be -and if these were declared- and why it didn't follow their own
guidance. If a COI is big enough to be declared in a medical journal, we
wanted to know why it wasn't big enough for WHO - who wield far more
influence and actually make policy recommendations.?
It is not for us to judge whether these interests were 'so financially
large', we have sought simply to use the WHO's own definitions. COIs are
not simply about the sum of money involved.

It's been widely reported in the academic literature that industry
funded trials and therefore its trialists are more likely to produce
results favourable to the company,

Guidelines on WHO guidelines (March 10 2003)

http://whqlibdoc.who.int/hq/2003/EIP_GPE_EQC_2003_1.pdf

Definition. Guidelines are systematically developed evidence-based
statements which assist providers, recipients and other stakeholders to
make informed decisions about appropriate health interventions. Health
interventions are defined broadly to include not only clinical procedures
but also public health actions. Guidelines are formal advisory statements
which should be robust enough to meet the unique circumstances and
constraints of the specific situation to which they are being applied.

On January 11, 2000, the HQ cabinet recommended that all WHO
guidelines should be evidence-based. An EIP-led intercluster initiative
developed this document as the recommended approach to development of WHO
guidelines.

PP15/16: Annexe A

Public health considerations have a primary importance in all WHO
technical work. Measures need to be taken to ensure that the best possible
assessment of scientific evidence is achieved in an independent atmosphere
free of either direct or indirect pressures. Thus, to assure the technical
integrity and impartiality of WHO's work, it is necessary to avoid
situations in which financial or other interests might affect the outcome
of that work.

Each expert is therefore asked to declare any interests that could
constitute a real, potential or apparent conflict of interest, with
respect to his/her involvement in the meeting or work, between (1)
commercial entities and the participant personally, and (2) commercial
entities and the administrative unit with which the participant has an
employment relationship. "Commercial entity" refers to any company,
association (e.g., trade association), organization or any other entity of
any nature whatsoever, with commercial interests.

In addition, as a result of WHO's strong stance against tobacco use, it is
considered relevant for the Organization to know whether experts working
with it have, or have had, any relationship with any part of what may be
called "the tobacco industry". Nevertheless, declaration of such an
interest would not necessarily be considered a reason to disqualify an
expert.

What is a conflict of interest?

Conflict of interest means that the expert or his/her partner ("partner"
includes a spouse or other person with whom s/he has a similar close
personal relationship), or the administrative unit with which the expert
has an employment relationship, has a financial or other interest that
could unduly influence the expert's position with respect to the subject-
matter being considered. An apparent conflict of interest exists when an
interest would not necessarily influence the expert but could result in
the expert's objectivity being questioned by others. A potential conflict
of interest exists with an interest which any reasonable person could be
uncertain whether or not should be reported.

Different types of financial or other interests, whether personal or with
the administrative unit with which the expert has an employment
relationship, can be envisaged and the following list, which is not
exhaustive, is provided for your guidance. For example, the following
types of situations should be declared:

1. a current proprietary interest in a substance, technology or process
(e.g. ownership of a patent), to be considered in - or otherwise related
to the subject-matter of - the meeting or work; [CURRENT]

2. a current financial interest, e.g. shares or bonds, in a commercial
entity with an interest in the subject-matter of the meeting or work
(except share holdings through general mutual funds or similar
arrangements where the expert has no control over the selection of
shares); [CURRENT]

3. an employment, consultancy, directorship, or other position during the
past 4 years, whether or not paid, in any commercial entity which has an
interest in the subject-matter of the meeting/work, or an ongoing
negotiation concerning prospective employment or other association with
such commercial entity; [PAST 4 YEARS]

4. performance of any paid work or research during the past 4 years
commissioned by a commercial entity with interests in the subject-matter
of the meetings or work; [PAST 4 YEARS]

5. payment or other support covering a period within the past 4 years, or
an expectation of support for the future, from a commercial entity with an
interest in the subject-matter of the meetings or work, even if it does
not convey any benefit to the expert personally but which benefits his/her
position or administrative unit, e.g. a grant or fellowship or other
payment, e.g. for the purpose of financing a post or consultancy. [PAST 4
YEARS]

How to complete this Declaration: Please complete this Declaration and
submit it to the Secretariat. Any financial or other interests that could
constitute a real, potential or apparent conflict of interest should be
declared (1) with respect to yourself or partner, as well as (2) with
respect to the administrative unit with which you have an employment
relationship.

Only the name of the commercial entity and the nature of the interest is
required to be disclosed, no amounts need to be specified (though they may
be, if you consider this information to be relevant to assessing the
interest). With respect to items 1 and 2 in the list above, the interest
should only be declared if it is current. With respect to items 3, 4 and
5, any interest during the past 4 years should be declared. If the
interest is no longer current, please state the year when it ceased. With
respect to item 5, the interest ceases when a financed post or fellowship
is no longer occupied, or when support for an activity ceases.

Assessment and outcome: The information submitted by you will be used
to assess whether the declared interests constitute an appreciable real,
potential or apparent conflict of interest. Such conflict of interest
will, depending on the situation, result in (i) you being asked not to
take part in the portion of the discussion or work affecting that
interest, (ii) being asked not to take part in the meeting or work
altogether, or (iii) if deemed by WHO to be appropriate to the particular
circumstances, and with your agreement, you taking part in the meeting or
work and your interest being publicly disclosed.
,br>Information disclosed on this Form may be made available to persons
outside of WHO only when the objectivity of the meeting or work has been
questioned such that the Director-General considers disclosure to be in
the best interests of the Organization, and then only after consultation
with you.

What the current WHO Declaration of Interests for WHO Experts say:

Public health considerations have a primary importance in all WHO
technical work.? Measures need to be taken to ensure that the best
possible assessment of scientific evidence is achieved in an independent
atmosphere free of either direct or indirect pressures.? Thus, to assure
the technical integrity and impartiality of WHO's work, it is necessary to
avoid situations in which financial or other interests might affect the
outcome of that work.
?
Each expert is therefore asked to declare any interests that could
constitute a real, potential or apparent conflict of interest, with
respect to his/her involvement in the meeting or work, between (1)
commercial entities and the participant personally, and (2) commercial
entities and the administrative unit with which the participant has an
employment relationship.? "Commercial entity" refers to any company,
association (e.g., trade association), organization or any other entity of
any nature whatsoever, with commercial interests.

What is a conflict of interest??
Conflict of interest means that the expert or his/her partner ("partner"
includes a spouse or other person with whom s/he has a similar close
personal relationship), or the administrative unit with which the expert
has an employment relationship, has a financial or other interest that
could unduly influence the expert's position with respect to the subject-
matter being considered.? An apparent conflict of interest exists when an
interest would not necessarily influence the expert but could result in
the expert's objectivity being questioned by others.? A potential conflict
of interest exists with an interest which any reasonable person could be
uncertain whether or not should be reported.
?
Different types of financial or other interests, whether personal or with
the administrative unit with which the expert has an employment
relationship, can be envisaged and the following list, which is not
exhaustive, is provided for your guidance.? For example, the following
types of situations should be declared:

1.a current proprietary interest in a substance, technology or
process (e.g. ownership of a patent), to be considered? in - or otherwise
related to the subject-matter of - the meeting or work;

2.a current financial interest, e.g. shares or bonds, in a commercial
entity with an interest in the subject-matter of the meeting or work
(except share holdings through general mutual funds or similar
arrangements where the expert has no control over the selection of
shares);

3. an employment, consultancy, directorship, or other position during
the past 4 years, whether or not paid, in any commercial entity which has
an interest in the subject-matter of the meeting/work, or an ongoing
negotiation concerning prospective employment or other association with
such commercial entity;

4. performance of any paid work or research during the past 4 years
commissioned by a commercial entity with interests in the subject-matter
of the meetings or work;

5. payment or other support covering a period within the past 4
years, or an expectation of support for the future, from a commercial
entity with an interest in the subject-matter of the meetings or work,
even if it does not convey any benefit to the expert personally but which
benefits his/her position or administrative unit, e.g. a grant or
fellowship or other payment, e.g. for the purpose of financing a post or
consultancy.
With respect to the above, an interest in a competing substance,
technology or process, or an interest in or association with, work for or
support by a commercial entity having a direct competitive interest must
similarly be disclosed.

How to complete this Declaration:? Please complete this Declaration
and submit it to the Secretariat.? Any financial or other interests that
could constitute a real, potential or apparent conflict of interest should
be declared (1) with
respect to yourself or partner, as well as (2) with respect to the
administrative unit with which you have an employment relationship. Only
the name of the commercial entity and the nature of the interest is
required to be disclosed, no amounts need to be specified (though they may
be, if you consider this information to be relevant to assessing the
interest). With respect to items 1 and 2 in the list above, the interest
should only be declared if it is current. With respect to items 3, 4 and
5, any interest during the past 4 years should be declared.? If the
interest is no longer current, please state the year when it ceased.? With
respect to item 5, the interest ceases when a financed post or fellowship
is no longer occupied, or when support for an activity ceases.

Assessment and outcome:?The information submitted by you will be used
to assess whether the declared interests constitute an appreciable real,
potential or apparent conflict of interest. Such conflict of interest
will, depending on the situation, result in (i) you being asked not to
take part in the portion of the discussion or work affecting that
interest, (ii) being asked not to take part in the meeting or work
altogether, or (iii) if deemed by WHO to be appropriate to the particular
circumstances, and with your agreement, you taking part in the meeting or
work and your interest being publicly disclosed.

Information disclosed on this Form may be made available to persons
outside of WHO only when the objectivity of the meeting or work has been
questioned such that the Director-General considers disclosure to be in
the best interests of the Organization, and then only after consultation
with you.

Declaration: Have you or your partner any financial or other interest
in the subject-matter of the meeting or work in which you will be
involved, which may be considered as constituting a real, potential or
apparent conflict of interest

Yes: No: If yes, please give details in the box below.

Do you have, or have you had during the past 4 years, an employment
or other professional relationship with any entity directly involved in
the production, manufacture, distribution or sale of tobacco or any
tobacco products, or directly representing the interests of any such
entityYes: No: If yes, please give details in the box below.

Is there anything else that could affect your objectivity or
independence in the meeting or work, or the perception by others of your
objectivity and independence

After large numbers of children in Finland and Sweden were vaccinated with the AS03-adjuvanted Pandemrix H1N1(v) vaccine, children's narcolepsy has increased more than tenfold in Finland, from ca. 3 a year in total [1] to 36 cases in the vaccine adverse event registry by 1 November this year [2] In Sweden, 43 cases of narcolepsy have been reported as suspected vaccine adverse events by 1 November.[2]

In Finland the agency responsible for collecting information on suspected adverse events of vaccines and acquiring vaccines for tax-paid vaccine programs is THL, National Institute for Health and Welfare. THL also has to responsibility to research suspected vaccine adverse events and is doing so with narcolepsy[6]. THL's website says the connection between Pandemrix and narcolepsy is "merely a temporal one" [7].

THL has conflicts of interest, as it has sizable (ca. 6 million euros year 2009) research funding from Pandemrix manufacturer GlaxoSmithKline [4,5].

[1] YLE (Finnish Broadcasting Corporation) news October 18, 2010, interview with Dr Markku Partinen, MD, PhD, former president of the World Association of Sleep Medicine

[2]
Helsingin Sanomat, November 1, 2010, writing by Dr Hanna Nohynek, MD, PhD, vaccine safety doctor, THL (National Institute for Health and Welfare)

[3]
Press release, THL (National Institute for Health and Welfare), 25 Aug 2010

[4] BMJ 2010; 340:c201,
"WHO vaccine expert had conflict of interest, Danish newspaper claims", BMJ 12 January 2010

[5] BMJ 2010; 341:c4755,
Drug company denies allegations of bribery in Finnish justice ministry investigation, BMJ 1 Sep 2010

[6]Special Team Investigating Narcolepsy Cases, YLE News 10 November 2010

[7]Q&A on narcolepsy, THL, undated, probably August 2010

On 28 April, 2009, when I was asked by the French international news channel to participate in a debate on the then hot topic of “pandemic” flu, my first answer was to refuse due to my lack of relevant skill in virology or infectious diseases (not to speak of a reluctance to improvise live in English…) Having finally accepted the invitation on the basis that we would be discussing the matter from the perspective of vaccine development, I did not consider myself to be displaying any extraordinary expertise in pointing out the following matters straightaway [1]: 1. There have been “previous instances” of false alarms, such as avian flu (1’32); 2. “this precedent of avian flu casts important doubts on the credibility of health agencies, national or international” (5’45); 3. “the real question is: who may have an interest in spreading alarming news?” (6’00); 4. viral mutation has been a regular occurrence in the history of flu without triggering such media alarm: what has changed is simply the availability of vaccine and antiviral drugs, the efficacy and safety of which remain to be documented (9’50).

In the companion debate recorded in French on the same day [2], I added that: i. there was no evidence of a major virulence associated with the new virus and the 200 reported Mexican deaths needed to be confirmed (they were reduced to a total of seven the following day); ii. the precedent of 1918 was clearly not relevant; iii. the official information on this new epidemic was a “rhetoric of intimidation”; iv. the conflicts of interest of the involved experts should be taken into consideration.

Taking as read that this analysis – by a non-expert – has now largely been confirmed, esp. by the recent BMJ/The Bureau of Investigative Journalism’s inquiry, the first question that presents itself is: why did the health profession take so long to detect the trick?

A second question might be: why did it take so long to get the measure of how the WHO goes about its business?  Is it clearly understood now that the scandal of the H1N1 pandemic was just a re-run of other, older stories (which go far beyond the vaccine sector)?

In 1997, in a widely circulated French journal [3], a Beecham’s business manager claimed: “We started increasing the awareness of the European Experts of the World Health Organization about hepatitis B in 1988 [emphasis added]. From then to 1991, we financed epidemiological studies on the subject to create a scientific consensus about hepatitis being a major public health problem. We were successful because in 1991, WHO published new recommendations about hepatitis B vaccination.” This speaks of exactly the same process as that which was uncovered by the BMJ/The Bureau of Investigative Journalism’s inquiry, namely: 1. WHO’s experts seem to need manufacturers’ salesmen to become “aware” of significant health problems; 2. recognition of “a major public health problem” involves commissioning epidemiological studies whose conclusions are apparently predetermined (“we financed epidemiological studies on the subject to create a scientific consensus”); 3. “new recommendations” are the main medium by which such commercial manipulations are effected, the long-term accuracy of which may be measured by the contrast between the initial skepticism of the BMA [4] and the views it expressed on the topic subsequently [5].

Moreover: exactly as in the case of the SAGE experts group, I have repeatedly pointed out regarding the benefit/risk ratio of the hepatitis B vaccination that the “WHO voice” was actually that of the Viral Hepatitis Prevention Board (VHPB), which was created, sponsored [6], and infiltrated by the manufacturers. Once again, in its “Technical consultation on the safety of hepatitis B vaccines” (Geneva, 28-30 Sept, 1998) – which (adding to unreliable epidemiological studies) was a major piece in the fight-back of manufacturers against growing evidence of vaccine hazards – the VHPB even did not try to make out that the manufacturers’ employees - some of them completely devoid of any expertise in the fields in question - had been invited as “observers”.  They were simply listed as “participants” in the “technical consultation”, like all the other participants.

A third question is related to the role of the regulatory agencies like the EMEA or the FDA, which – in contrast to the WHO – have the regulatory power of decision. This should be an opportunity to ask how, during the development of a vaccine targeted against a disease as mild as the H1N1 flu, the recording of no fewer than seven deaths in about 2000 healthy persons receiving Pandemrix as a test drug was regarded as acceptable, or that the statistical power to detect adverse events with the new vaccines did not go beyond…1% of exposed subjects (there is a worrying consensus in certain quarters that a serious audit of EMEA processing should not take place [7]). Furthermore, this could be an opportunity to review the progressive drift in European legislation which now permits the development of a new flu vaccine simply to be treated as a type II variation, an incredible regulatory coup for manufacturers. And to understand the recent history of the development and registration of H1N1 vaccines as a precedent for other future regulatory situations that will be governed by the new European directive amending, as regards pharmacovigilance, Directive 2001/83/EC - a regulation which would be nothing short of a disgrace.

A last question arises from the following observation: in this recent story of swine flu, whose financial stakes for manufacturers the manufacturers did not even attempt to deny (see media on economy), nobody heard the manufacturers’ voices in the promotion of swine flu as a major threat to public health consisted entirely of national and international health or governmental agencies. This illustrates JK Galbraith’s recent thesis on The Predator State [8], namely that “deregulation” is not the law of jungle for the lobbies’ benefit, but the surrendering of the State’s power and prerogatives to those lobbies, whatever the cost to public health or finances (see, for example, in France, requisitioning in the desperate hope of liquidating the vaccine stocks).

Finally, the H1N1 scandal is a new opportunity to challenge the view that conflicts of interests do not threaten experts’ independence as their links to commercial enterprises are simply the price of their scientific excellence. I would make the following points. First, this self-serving claim of independence is contradicted by a heap of published data, in particular data related to the sometimes subtle determinants of the “funding effect”. Second, firms and lobbies have the power to select who they think deserve to be recognized as an “expert”; excellence of itself is by no means the determinant of this selection [9].

The attached histogram summarizes the evolution of my turnover from the time I was a respected (and well-off) consultant to the leaders of pharmaceutical industry who were my clients until today.  The interesting detail is that between 2000 and 2006 I was commissioned as an expert by French Judges on a number of occasions in litigation involving pharmaceutical companies and some of my expert reports received wide media coverage.  Another detail of potential relevance is that, on the whole, these reports were less favourable to the interests of my clients than the recommendations of “independent” experts regarding swine flu.

References

1. France 24 International News. Swine flu: unfounded panic? 28 April,
2009, http://www.france24.com/en/20090428-wbenfaceoff12h12m090428flv-
girard-bader-swine-flu-media-panic-real

2. France 24. Grippe : des peurs irrationnelles ? 28 April, 2009,
http://www.france24.com/fr/20090428-grippe-porcine-epidemie-oms

3. Labbé C, Le Taillanter M, Recacens O, et al. L'habile stratégie
d’un labo. Sciences et Avenir, January 1997, p 27.

4. D Carnall. Shire Hall. Communication and the case for hepatitis B
immunization. BMJ 1996; 313: 825

5. AJ Pollard. Hepatitis B vaccination. BMJ 2007;335:950 (10
November), doi:10.1136/bmj.39315.677396.BE

6. Anon. Good news on hepatitis B vaccination in Europe. Scrip
1997(2288):22.

7. M Girard. No H1N1 enquiry committee in the European Parliament;
http://www.rolandsimion.org/spip.php?article139〈=en

8. JK Galbraith. The Predator State. New York, Free Press, 2008

9. Girard M. Expert mongering.
http://bmj.bmjjournals.com/cgi/eletters/329/7459/189#70360

Competing interests:
Marc Girard is or has been consultant for pharmaceutical firms, including most of those currently involved in the H1N1 scandal

The UK government's Department of Health issued a statement on 15 May
2009 that included; "If a pandemic is declared, Advance Supply Agreements
signed by the Government with GSK and Baxter in July 2007, will enable the
UK to purchase up to 132 million doses of pandemic specific vaccine, when
it becomes available." [1]

The Secretary of State for Health, Alan Johnson, issued a release the
same day which stated, "We have Advance Purchase Agreements to provide
vaccine for the entire UK population which will take effect when Phase 6
pandemic is declared." and also referred to Advance Supply Agreements
signed by the government with GlaxoSmithKline and Baxter in July 2007. [2]

A September 2008 planning document of the US government refers to
several European countries having Advance Purchase Agreements and refers
to a speech given by the former Chief Medical Officer in 2006 stating that
there were 'agreements with several suppliers to deliver 150 million doses
of vaccine as soon as possible in the event a pandemic is identified.'[3,
4]

[1] http://tinyurl.com/389rjyh

[2] http://www.direct.gov.uk/en/Swineflu/News/DG_178226

[3] Congressional Budget Office, U.S. Policy Regarding Pandemic-
Influenza Vaccines September 2008

[4] http://tinyurl.com/2dayfwb 30 June: Wood Memorial Lecture Title:
Global Health Strategies for Global Health Threats (Venue: Fort
Blockhouse, Gosport, Hants)

Competing interests:
None declared