Did the hesitancy in declaring COVID-19 a pandemic reflect a need to redefine the term?
Authors: Manfred S Green
Journal: The Lancet (2020)

WHO's declaration that the global spread of coronavirus disease 2019 (COVID-19) is a pandemic1WHOWHO Director-General's opening remarks at the media briefing on COVID-19 - 11 March 2020.https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020Date: March 11, 2020Date accessed: March 11, 2020Google Scholar has contributed greatly to clearing up confusion in the terminology in the professional literature and the media. Discussions on when wide geographical spread of a disease becomes a pandemic tend to recur when the world is confronted with an emerging infectious disease.2Cohen J Enserink M Swine flu. After delays, WHO agrees: the 2009 pandemic has begun.Science. 2009; 324: 1496-1497Crossref PubMed Scopus (74) Google Scholar, 3Doshi P The elusive definition of pandemic influenza.Bull World Health Organ. 2011; 89: 532-538Crossref PubMed Scopus (107) Google Scholar The debate around the terminology used for COVID-19 raises two important questions. The first question is why there was reluctance to call the COVID-19 outbreak a pandemic, and the second question is whether the terminology is of any practical importance. In almost all good textbooks, an epidemic becomes a pandemic when there is widespread geographical distribution of the disease. For some weeks, the COVID-19 epidemic, which had spread to over 100 countries, seemed to fit the classical definition of a pandemic. One could reasonably ask whether the use of the term pandemic would change any of the actions necessary to control the spread of the virus. There are several situations in which it could be helpful to use well defined terminology to control the spread of an infectious disease. The resources for controlling a pandemic are both different, substantially larger, and generally much more far-reaching than for a localised outbreak or epidemic. Thus the terms used for the different situations could be restricted according to the control measures that are necessary. Perhaps unique to pandemics, these include considerable international coordination and collaboration in providing aid to affected countries, recruiting the necessary resources for promoting research on medications and vaccines and developing complex risk communication. In particular, travel restrictions become a major issue and, although these are guided by the International Health Regulations, countries have the option to adopt unilaterally their own barriers to international travel. This was clearly the case for COVID-19. If the term pandemic is clearly defined, it can communicate much more clearly the seriousness of the situation and help justify the extreme measures instituted. It can also provide the international health community with a common term to enlist the cooperation of the general public and convey the necessary sense of urgency to decision makers. This should stimulate rapid introduction of preventive measures such as social distancing to reduce the pace of the spread, providing valuable time for upgrading of the medical services, and preparing the community. If the use of the term pandemic is delayed too long, the declaration of the pandemic could convey a message to the public that the authorities have lost control, generating irrational panic reactions. Since it is expected, and even perhaps desirable, that the public experience some fear during a pandemic, an early declaration of a pandemic might be helpful in mitigating panic. Recruiting public cooperation is much more feasible when the society in general and the health services in particular are not yet under considerable pressure, and there is time for appropriate explanations to the public as to how the pandemic will be controlled. The question remains as to what is the optimal timing for declaring a pandemic. Following the 2009 H1N1 pandemic, Morens and colleagues4Morens DM Folkers GK Fauci AS What is a pandemic?.J Infect Dis. 2009; 200: 1018-1021Crossref PubMed Scopus (167) Google Scholar provided useful criteria for defining a pandemic. They included the following components: the cause should be a new virus that has not circulated in humans previously, the disease should be widespread geographically, there should be clear person-to-person spread, and outbreaks should be explosive in nature, with a relatively high case-fatality rate. It seems to me that for some time, the COVID-19 outbreak met all these criteria. Since there continues to be a lack of consensus about when it is appropriate to use the term pandemic, I suggest that a multi-disciplinary group of epidemiologists, infectious disease specialists, risk communicators and health administrators be convened to create new, clearer, expanded definitions of the terms outbreak, epidemic, and pandemic. I declare no competing interests.