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Rapid response to:


Governments must be pulled up for failings over flu

BMJ 2009; 338 doi: (Published 15 May 2009) Cite this as: BMJ 2009;338:b2019

Rapid Response:

Pulling up governments for trying to pull down the pandemic alert level

In his Observations article from 15 May 2009, "Governments must be
pulled up for failings over flu,"[1] Andrew Jack writes: “To most people,
a pandemic with a lower human impact than seasonal flu is no pandemic at

That may be true, but on the other hand most people have no notion of
the human impact of a seasonal flu. Even with the increased publicity
resulting from the Swine Flu outbreak, few among the general public would
guess that the seasonal flu kills between 250 000 and 500 000 people
worldwide every year.[2] (A little more than the population of Brighton
to a little less than the population of Sheffield, according to the 2001
Census.)[3] Indeed, even many people who should know better think that
common symptoms of the flu are nausea and vomiting or diarrhea.[4] Shared
ignorance is not the equivalent of wisdom.

Mr. Jack asserts that we should pull up governments for their
failings in responding to this flu outbreak, and he’s right. But one of
the most important of these failings has been the misguided effort by many
member nations to have the WHO redefine what counts as a flu pandemic.
The politicians calling for this measure would have us leave both science
and logic behind in order to ensure that the WHO does not raise the
Pandemic Alert Level to Phase 6 (a declared pandemic). Their rationale is
that the disease is not severe enough to be called a pandemic.

The UK, one of the nations which has taken this stance,[5]
acknowledges in its own pandemic influenza planning document that the
severity of historical flu pandemics “…has ranged from something similar
to seasonal influenza to a major threat…”[6] Apparently, this internal
contradiction leaves the government unfazed.

If the WHO redefines the official criteria for declaring a flu
pandemic such that the Swine Flu does not qualify, we will have to erase
the 1957 and 1968 pandemics from the history books, because they were in
the same class.

A pandemic is quite simply “…a disease that is epidemic on a
worldwide scale over a similar time span.”[7] Severity does not enter into
it –and shouldn’t. The world needs to know when a pandemic has struck,
even if it is not terribly virulent. Because even a “mild” pandemic can’t
be trusted to stay that way.

The first wave of infections caused by the 1918 pandemic virus were
in no way severe. It wasn’t until the second wave struck, during the fall
flu season, that the virus turned deadly. If the same thing should happen
with this virus, and if the world finds itself unprepared because the WHO
claimed this virus was too mild even to count as a pandemic, the resulting
loss of life could be staggering.

The only responsible course of action is for the WHO to acknowledge
reality and raise the Pandemic Alert Level to Phase 6. They can use the
resulting publicity to better educate the public about what that does (and
doesn’t) mean, while stressing the steps people can take to protect
themselves. Otherwise, this much-needed organization will be betting
every last shred of its credibility on the stability of an influenza A
virus. Those aren’t odds I would care to take.


1. Jack A. Governments must be pulled up for failings over flu. BMJ.
2009 May 15;338:b2019. doi: 10.1136/bmj.b2019.

2. World Health Organization. Influenza. Accessed 25 May 2009.

3. Office for National Statistics. Census 2001. Accessed 25
May 2009.

4. Ofstead CL, et al. Influenza vaccination among registered nurses:
information receipt, knowledge, and decision-making at an institution with
a multifaceted educational program. Infect Control Hosp Epidemiol. 2008

5. O'Dowd A. UK urges more flexibility in criteria for flu pandemic
alerts. BMJ. 2009 May 21;338:b2067. doi: 10.1136/bmj.b2067.

6. Department of Health. Pandemic Flu: A National Framework for
Responding to an Influenza Pandemic. 22 November 2007. Available from:

7. Fleming D. Influenza pandemics: why, what, and how to prepare. BMJ
Learning. Available from:

Competing interests:
None declared

Competing interests: No competing interests

25 May 2009
Alan J. Card
Evidence-Based Health Solutions, LLC; 303 Bowen Rd; Davenport, FL 33837; USA