Doc. 12283
7 June 2010
The handling of the H1N1 pandemic: more transparency needed
Report1
Social Health and Family Affairs Committee
Rapporteur: Mr Paul FLYNN, United Kingdom, Socialist Group
Summary
On 11 June 2009, the World Health Organization (WHO) officially declared “Pandemic
(H1N1) 2009”. The way in which the H1N1 influenza pandemic has been handled, not
only by WHO, but also by the competent health authorities at the level of the European
Union and at national level, gives rise to alarm. Some of the consequences of decisions
taken and advice given are particularly troubling, as they led to distortion of priorities
of public health services across Europe, waste of large sums of public money and also
unjustified scares and fears about health risks faced by the European public at large.
Grave shortcomings have been identified regarding the transparency of decisionmaking processes relating to the pandemic which have generated concerns about the
possible influence of the pharmaceutical industry on some of the major decisions
relating to the pandemic. It must be feared that this lack of transparency and
accountability will result in a plummet in confidence in the advice given by major public
health institutions.
The Parliamentary Assembly has shed light on the handling of the H1N1 pandemic in
the most comprehensive manner possible and through an open dialogue with WHO and
other players. It welcomes the review processes that have been initiated by various
public health authorities, including WHO, and urges all stakeholders concerned to share
the results in order to learn from experience and ensure that responsibility is taken for
any errors made. The Assembly considers that a thorough review of existing
governance systems and the immediate communication of essential information not yet
published are of utmost importance in order to re-establish confidence in major public
health decisions and advice with a view to ensuring that they be followed in the case of
the next infectious disease of global scope, which may well be more severe.
A.

Draft resolution2

1.
The Parliamentary Assembly is alarmed about the way in which the H1N1
influenza pandemic has been handled, not only by the World Health Organization
(WHO) but also by the competent health authorities at the level of the European Union
and at national level. It is particularly troubled by some of the consequences of
decisions taken and advice given leading to distortion of priorities of public health
services across Europe, waste of large sums of public money and also unjustified
scares and fears about health risks faced by the European public at large.
2.
The Assembly notes that grave shortcomings have been identified regarding the
transparency of decision-making processes relating to the pandemic which have
generated concerns about the possible influence of the pharmaceutical industry on
some of the major decisions relating to the pandemic. The Assembly fears that this
lack of transparency and accountability will result in a plummet in confidence in the
advice given by major public health institutions. This may prove disastrous in the case
of the next disease of pandemic scope - which may turn out to be much more severe
than the H1N1 pandemic.
3.
The Assembly recalls its previous work on good governance in the public health
sector in Council of Europe member states, in particular Recommendation 1725 (2005)
on Europe and bird flu – preventive measures in the health field and Recommendation
1787 (2007) on the precautionary principle and responsible risk management”. In

Recommendation 1908 (2010) on lobbying in a democratic society (European Code of
conduct on lobbying), the Assembly noted that unregulated or secret lobbying may be
a danger and can undermine democratic principles and good governance.
4.
On a positive note, the Assembly welcomes the review and evaluation processes
regarding the handling of the H1N1 pandemic recently launched or about to be
launched by WHO, European institutions dealing with health issues and a number of
national governments and parliaments. The Assembly urges all parties concerned to
continue and reinforce dialogue between public health institutions at all levels and hold
more regular exchanges on good governance in the health sector in the future.
5.
Notwithstanding the willingness of WHO and the European health institutions
concerned to enter into a dialogue and conduct a review of the handling of the
pandemic, the Assembly seriously regrets that they have not been willing to share
some essential information, in particular to publish the names and declarations of
interest of the members of the Emergency Committee of WHO and relevant European
advisory bodies directly involved in recommendations concerning the handling of the
pandemic. Furthermore the Assembly regrets that WHO has not moved swiftly to revise
or re-evaluate its position on the pandemic and the real health risks involved, despite
the overwhelming evidence that the seriousness of the pandemic was vastly overrated
by WHO at the outset. In addition the Assembly regrets the highly defensive stance
taken by WHO, whether in terms of being unwilling to accept that a change in definition
of a pandemic was made, or an unwillingness to revise its prognosis on the pandemic.
6.
In the light of the widespread concerns raised over the handling of the H1N1
pandemic, the Assembly calls on public health authorities at international, European
and national level – and notably WHO– to address in a transparent manner the
criticisms and disquiet raised in the course of the H1N1 pandemic, by:
6.1.
reviewing the terms of reference of their general governance bodies
and special advisory bodies wherever appropriate with a view to ensuring
utmost transparency and the highest level of democratic accountability
regarding public health decisions;
6.2.
agreeing in a transparent manner on a common set of definitions and
descriptions concerning influenza pandemics, involving a cross section of
expertise, in order to generate a coherent world-wide understanding of such
events;
6.3.
revising and updating existing guidelines on working with the private
sector or preparing such guidelines where they are lacking, in order to ensure
that:
6.3.1.
a wide range of expertise and opinions are taken into
account, including contrary views of individual experts and opinions of
non-governmental organisations;
6.3.2.
declarations of interest of experts involved are made public without
exception;
6.3.3.
collaborating external organisations are obliged to indicate
their link with key opinion leaders or other experts possibly subject to
conflicts of interest;
6.3.4.
all persons subject to conflicts of interest are excluded from
sensitive decision-making processes;
6.4.
revising communication strategies related to public health matters by
taking into account the current social context marked by a high level of access
to new technologies and by closely collaborating with the media in order to
avoid sensationalism and scaremongering in the public health domain;
6.5.
refining and preparing the grounds for the proper use of the
precautionary principle in health matters in the future, including through the

preparation of fully transparent communication strategies and accompanying
education and training measures;
6.6.
sharing the results of H1N1 pandemic review processes in the most
transparent and comprehensive manner possible amongst all stakeholders
concerned, including WHO, European institutions (European Union and Council
of Europe), national governments and parliaments, non-governmental
organisations and the European public at large, in order to learn from
experience, ensure that responsibility is taken for any errors made, and reestablish public confidence in public health decisions and advice;
7.
The Assembly furthermore invites WHO, and possibly European health
institutions concerned, to engage in more regular European exchanges on the issue of
good governance in the health sector by:
7.1.
participating in more regular debates on topics related to good
governance in the health sector within the Parliamentary Assembly;
7.2.
actively contributing to the intergovernmental work undertaken at
Council of Europe level on good governance in the public health sector;
8.

The Assembly also calls on member states to:
8.1.
make use of their means of democratic control through the internal
governance systems of WHO and European institutions, with a view to
ensuring that this resolution is properly implemented;

8.2.

launch critical review processes at national level if they have not yet done so;
8.3.
develop systems of safeguards against undue influence by vested
interests if they have not yet done so;

8.4.

ensure stable funding for WHO;
8.5.
consider establishing a public fund to support independent research,
trials and expert advice, possibly financed by an obligatory contribution of the
pharmaceutical industry;
8.6.
ensure that the private sector does not gain undue profit from public
health scares and that they are not allowed to absolve themselves of liabilities
with a view to privatising profits whilst communitising risks. In order to avoid
this, member states should be ready to develop and implement clear national
guidelines for dealing with the private sector and to co-operate with one
another in negotiations with international corporations whenever necessary.

9.
The Assembly invites national parliaments to support national policies aimed at
the improvement of governance systems in the public health sector and ensure that
they are involved in relevant national review and policy-making processes in order to
guarantee the highest democratic accountability possible.
10.
Finally, the Assembly invites the pharmaceutical industry, including
corporations and associations, to revise their own rules and functioning regarding cooperation with the public sector in order to ensure the highest degree of transparency
and corporate social responsibility when it comes to major public health matters.
B.

Draft recommendation3

1.
Referring to its Resolution … (2010) on “The handling of the H1N1 pandemic:
more transparency needed”, the Parliamentary Assembly notes that there is an urgent
need for a thorough review of recent decisions taken by public health authorities at
international, European and national level in the framework of the H1N1 pandemic
given that a lack of transparency in public decisions undermines democratic principles
and good governance.

2.
At a time when the current H1N1 pandemic is reaching its final phase, notably in
Europe, and when internal review processes of its handling have just begun within
WHO, European institutions and national governments, the Assembly urges all
authorities involved to recognise the shortcomings identified by the Assembly and
implement the measures recommended in its Resolution … (2010).
3.
The Assembly considers that only a comprehensive and transparent review of
decisions and decision-making processes related to the H1N1 pandemic and the
subsequent reorientation of public health policies and governance systems will ensure
that public confidence in major public health institutions is rebuilt and that national
governments and European citizens will follow their advice in future situations involving
substantial risks to public health.
4.
The Assembly considers that the issue of good governance in the health sector
should be one of the priorities of the intergovernmental activities at the Council of
Europe given the importance of democratic accountability and transparency in public
health decision-making. The Assembly therefore welcomes the recent adoption of
Recommendation CM/Rec(2010)6 of the Committee of Ministers to member states on
good governance in health systems and the follow-up activities planned with a view to
its implementation. It supports the setting up of an expert committee, under the
European Health Committee (CDSP), to evaluate and monitor the implementation of
Recommendation CM/Rec(2010)6.
5.
5.1.

The Assembly moreover calls on the Committee of Ministers to :
instruct the European Health Committee (CDSP) and related bodies to:
5.1.1.
take into account Resolution… (2010) of the Assembly when
it comes to defining the work programme and the indicators to be
followed in monitoring processes related to good governance in the
public health sector;
5.1.2.
not only “monitor and evaluate”, but also promote good
governance of health systems in all Council of Europe member states
through appropriate complementary working methods such as
assistance programmes or best practice exchanges wherever
considered useful;
5.1.3.
launch a parallel work process towards the preparation of a
Council of Europe Code of good governance taking into account the
threats to good and democratic governance identified during the H1N1
crisis, as well as the lessons learned from it;
5.2.
encourage member states to actively participate in these Council of
Europe activities and promote Recommendation CM/Rec(2010)6 with a view to
its rapid implementation at national level and its consideration when it comes
to national review processes concerning the H1N1 pandemic;
5.3.
closely observe future debates to be held on good governance in the
health sector within the Assembly and take into consideration the outcomes of
such debates for the orientation of the intergovernmental work at Council of
Europe level.

C.

Explanatory memorandum by Mr Flynn, rapporteur

“The United Nations and business need each other. We need your innovation, your
initiative, your technological prowess. But business also needs the United Nations. In a
very real sense, the work of the United Nations can be viewed as seeking to create the
ideal enabling environment within which business can thrive.”
United Nations Secretary-General Ban Ki-moon4
*****

We are supposed to be prepared for a pandemic of some kind of influenza because the
flu watchers, the people who make a living out of studying the virus and who need to
attract continued grant funding to keep studying it, must persuade the funding
agencies of the urgency of fighting a coming plague”.
Professor Philip Alcabes in “Dread” 5
Table of contents
1. Introduction

Page
5

2. Global response to the H1N1 pandemic – basic facts and perception

6

3. Handling the H1N1 pandemic - transparency and accountability of public health
action?
8
a. The role of the World Health Organization (WHO)
b. The role of the pharmaceutical industry

8

13

c. The role of member states and their health authorities
d. The role of European Union bodies
4. Conclusions – Recommendations
5. Appendix:

15

17
18

Visit to the WHO, Geneva, 15 April 2010.

Written responses by WHO to the questions presented by the rapporteur
1.

Introduction

1.
The Parliamentary Assembly pays particular attention to governance issues in
the public health sector in Council of Europe member states. Recent activities of
relevance have been Recommendation 1725 (2005) on “Europe and bird flu –
preventive measures in the health field”, Recommendation 1787 (2007) on “The
precautionary principle and responsible risk management” and Recommendation 1908
(2010) on “Lobbying in a democratic society (European Code of conduct on lobbying)”.
2.
In December 2009, a motion was tabled under the title “Faked Pandemics - a
threat for health” by Dr Wolfgang Wodarg (Germany, SOC), outgoing member of the
Parliamentary Assembly and medical expert specialising in epidemiology. The Social,
Health and Family Affairs Committee was mandated by the Assembly to prepare a
report and appointed Paul Flynn (United Kingdom, SOC) as its rapporteur. At this time,
the H1N1 pandemic had already been treated as a major public health issue for more
than half a year by most Council of Europe member states after having been officially
declared by the World Health Organisation (WHO).
3.
The rapporteur is greatly concerned by the handling of the H1N1 influenza
pandemic, the decisions taken by the WHO and competent authorities at European
level and the advice given to the 47 member states of the Council of Europe. He is
particularly alarmed by some of the excessive responses given to what turned out to
be an influenza of moderate severity, and also the lack of transparency of relevant
decision-making processes and the possible undue influence of pharmaceutical groups
on central decisions. Furthermore he is concerned by the way in which some of the
sensitive issues were communicated by public authorities and subsequently picked up
by the European media, reinforcing fears amongst the population which sometimes
made objective analysis difficult. The aim of this report is to make the ongoing debate
on the pandemic more objective at a European level and to identify shortcomings and
lessons learned from the H1N1 crisis, not least in the hope of rebuilding public
confidence in health decisions which have been taken by WHO and by European and
national authorities.
4.
The rapporteur welcomes WHO’s readiness to enter into an open dialogue with
national parliamentarians represented at the Council of Europe Parliamentary

Assembly. He recognises the outstanding achievements made in public health in recent
decades and the essential contribution of WHO to these. However, it is regrettable that
the WHO has not been willing to share some essential information with the Assembly
regarding, in particular, membership of and possible conflicts of interest of experts on
a key advisory body within WHO.
5.
When it comes to examining the handling of the H1N1 influenza and drawing
relevant conclusions, the rapporteur assigns utmost importance to the close cooperation between all stakeholders involved. These include, in addition to the Council
of Europe and its Parliamentary Assembly, WHO and competent bodies of the European
Union, as well as national governments, the pharmaceutical industry, academia and
civil society. A broad and open dialogue was held at two public hearings held on 26
January and 29 March 2010 and through a visit by the rapporteur and the Chair of the
Social, Health and Family Affairs Committee to WHO’s headquarters in Geneva on 15
April 20106. The Committee held an exchange of views with Dr Fiona Godlee (Editor in
Chief of the British Medical Journal – BMJ) on 4 June 2010 in Paris before the adoption
of the report.
2.

Global response to the H1N1 pandemic – basic facts and perception

Declaration of a pandemic
6.
WHO describes the H1N1 virus as an influenza virus that had never been
identified as a cause of infections in people before the current pandemic. Genetic
analyses of this virus have shown that it originated from animal influenza viruses
(which explains its common denomination as “swine flu”) and is unrelated to the
human seasonal H1N1 viruses that have been in general circulation since 1977. There
seems to be evidence that antibodies to the seasonal H1N1 virus do not protect against
the pandemic H1N1 virus. However, other studies have shown that a significant
percentage of the population aged 65 and older do have some immunity against the
pandemic virus. This suggests that some persons may have had some cross protection
from exposure to viruses that have circulated in the more distant past. Unlike typical
seasonal flu patterns in the northern hemisphere, the new virus caused high levels of
summer infections. Subsequently infections reached even higher levels of activity
during cooler months.
7.
During the initial phases of the H1N1 influenza, infections were reported in 9
countries on 29 April 2009, then cases were confirmed in 74 countries and territories
on 11 June, and just a few weeks later, on 1 July, there were confirmed infections in
120 countries and territories around the world. It was this global spread which led
WHO to declare increasing phases of pandemic emergency and inform the world that a
pandemic was definitely under way7. On 11 June 2009, the pandemic was thus officially
declared by designating the situation as pandemic influenza phase 68. This declaration
at a very early stage of the event and shortly after the detection of first infections in
Mexico in April 2009 was, according to some experts, only possible because the
description of pandemic alert phases was modified by WHO in May 2009, and notably
the criteria relating to the severity of the disease removed as a pre-condition for
passing on to the highest alert level9.
Numbers of infections and deaths
8.
As of May 2010, most countries in the world had confirmed infections of the
virus. As of 25 April 2010, more than 214 countries and overseas territories or
communities worldwide had reported laboratory confirmed cases of pandemic influenza
H1N1, including over 17 919 deaths. WHO continues to actively monitor the progress
of the pandemic through frequent consultations with WHO Regional Offices and
member states10. Firm conclusions on the outbreak of the pandemic were to be
reached after April 2010, the month when a normal influenza season usually ends;
however these have not as yet been published by WHO. Reliable estimates of the
number of deaths and the mortality rate during the current pandemic will only be
possible, according to WHO, one or two years after the pandemic has ended11. At the
time of preparation of this report, rates of influenza in Europe had gone down and the
pandemic virus was only being detected sporadically. The Global Influenza Surveillance
Network (GISN) continues monitoring the global circulation of influenza viruses,

including pandemic, seasonal and other influenza viruses infecting, or with the
potential to infect, humans.12
9.
Beyond mere numbers of infections, the new virus apparently led to patterns of
death and illness not normally seen in seasonal influenza infections. Most of the deaths
caused by the pandemic influenza seemed to have occurred among younger people,
including those who were otherwise healthy. Pregnant women, younger children and
people of any age with certain chronic lung or other medical conditions appeared to be
at higher risk of more complicated or severe illness. According to recent information
from the European Centre for Disease Prevention and Control (ECDC), while symptoms
of the disease were mild in most people, only a significant minority of people suffered
severe disease and died as a result.13
Vaccination strategies
10.
The declaration of a new pandemic caused by the H1N1 virus and the
designation of pandemic
phase 6 initiated an immediate international agenda setting process and the
implementation of vaccination strategies at national level. National regulatory
authorities generally licensed or approved vaccines developed by various vaccine
manufacturers according to relevant national procedures, sometimes following
accelerated procedures in order to make relevant vaccines available more rapidly. WHO
was involved from the very start in the vaccination process by mobilising global
resources and coordinating the distribution of donated pandemic influenza vaccine to
eligible countries in order to help them protect people from developing the H1N1
infection14.
11. National reactions to the declaration differed widely. Some of the vaccination
campaigns run at national level were extensive, others were minimal. Several
European countries had already prepared the ground for a pandemic and had prepared
so-called “sleeping contracts” with pharmaceutical groups which were to take effect on
the declaration of a pandemic by WHO15. Some countries followed recommendations by
pharmaceutical groups that the vaccination should be given twice in order to ensure
full protection against the virus and had therefore purchased corresponding quantities
of vaccines. Some of the far-reaching approaches followed were justified by
‘pessimistic’ predictions of numbers of infections and deaths to be expected as a result
of the pandemic.
Differing perceptions
12.
From the very beginning of the disease in April 2009, it was clear that a newly
combined flu virus was on its way, just as many flu virus variations had, in the past,
been seen on an almost annual basis. However, from this common perception, the
H1N1 influenza was looked at from different perspectives by member states’
governments as well as within the medical community. Already in summer 2009, some
independent medical experts raised warnings regarding the overestimation of the
current influenza pandemic. They raised concerns about excessive vaccination
activities, risks of side-effects of certain vaccines, the ineffectiveness of some of the
medication, as well as possible undue influence by biased advisors16. It was precisely
these warnings which drew the Parliamentary Assembly’s attention to the issue and
prompted it to take up the topic and ask for the preparation of the current report.
3.
Handling the H1N1 pandemic - transparency and accountability of public
health action?
13.
All arguments presented by critics in recent debates seem to have one
common focal point: the disparity between the relatively mild unfolding of the influenza
as it appeared in the autumn of 2009 and the far-reaching action taken at European
and national level in some countries. The criticisms raised by various international
experts with regard to the way in which the H1N1 pandemic was handled are focused
on some of the specific measures taken by the various stakeholders concerned notably
WHO, the pharmaceutical groups, national governments and European Union bodies.
The rapporteur’s analysis therefore focuses on their respective action with a particular
emphasis on decision-making processes in and around WHO. It was the declaration of
a pandemic by WHO on 11 June 2009 and its subsequent recommendations which

triggered the international agenda setting process and subsequent action for the
implementation of vaccination strategies; the role of WHO therefore merits special
attention.
14.
The rapporteur would like to point out that this analysis of the H1N1 pandemic
was an extremely complex issue given that the actions taken by all stakeholders were
closely intertwined. The research process of the Assembly itself seemed to have had an
influence on some of the subsequent reactions of responsible organisations triggering
review processes. In this respect the rapporteur welcomes the general readiness of
organisations concerned to enter into an open dialogue with the Assembly. Not all
questions have however been answered and some of the most sensitive issues still
need to be dealt with.
a.

The role of the World Health Organization (WHO)

15.
According to its Constitution17, the objective of the WHO shall be the
attainment by all peoples of the highest possible level of health. It coordinates and
directs international health work, provides technical assistance and aid in emergencies.
It develops an informed public opinion on health matters and seeks to eradicate
epidemic, endemic and other diseases. WHO is therefore the international authority on
public health recommendations for the 193 member states of the Organisation. In the
light of its overwhelming success regarding the eradication of major human diseases
(such as smallpox) and the control of others, WHO rightly benefits from its member
states’ highest respect and active support and collaboration through specially designed
governance structures.
Governance system of WHO and bodies concerned by pandemic situations
16.
The World Health Assembly is the supreme decision-making body of WHO. It
generally meets in Geneva and is attended by delegations from all member states. Its
main function is to determine the policies of the Organization. The Health Assembly
appoints the Director-General, supervises the financial policies of the Organisation and
reviews and approves the proposed programme budget. It similarly considers reports
of the Executive Board, which it instructs in regard to matters upon which further
action, study, investigation or report may be required. The WHO Executive Board is
composed of 34 members technically qualified in the field of health and members are
elected for three-year terms. Member states of WHO are further represented in six
Regional Committees meeting yearly.
17.
One of the main WHO bodies concerned in situations related to pandemic
diseases is the Strategic Advisory Group of Experts (SAGE), serving as the principal
advisory group for the development of policy related to vaccines and immunization at a
strategic rather than a technical level. The SAGE comprises 15 members who are
appointed for an initial term of three years (to be renewed only once), who serve in
their personal capacity and who represent a broad range of disciplines proportionally
represented in both geography and gender. SAGE’s terms of reference as well as its list
of members are made available through the WHO website. Before being appointed, all
members have to sign a declaration of interest with the purpose of excluding conflicts
of interest between any of their professional activities and their advisory function
within WHO.
18.
Under the provisions of the International Health Regulations (IHR) of 2005, the
WHO Director-General may also appoint an Emergency Committee for special advice on
matters related to acute public health events and emergencies of international concern.
In response to cases of swine influenza A(H1N1), reported in Mexico and the United
States of America, the Director-General convened a first Emergency Committee
meeting on 25 April 2009 to assess the situation and advise her on appropriate
responses. The membership of this Committee is not public. It is on the basis of advice
from this Committee that WHO declared the H1N1 pandemic on 11 June 2009.
Proportionality and appropriateness of the response
19.
When looking at the still very moderate expression of the pandemic almost one
year after its outbreak (May 2010), the interpretation of scientific and empirical
evidence can be seriously questioned. For some experts, it seemed obvious from a

relatively early stage that the new sub-type of influenza virus was doing less harm to
persons infected than other forms of the virus in previous years. As one epidemiologist
stated: “the importance of influenza is completely overestimated. It has to do with
research funds, power, influence and scientific reputations”18. For those however in
favour of far-reaching measures, these considered them justified by the ‘precautionary
principle’. It would appear that numerous scientists had expected the outbreak of a
new world-wide pandemic for a long time and were therefore extremely sensitive to the
possible dramatic consequences of any new viruses. Moreover, the possible mutation of
the swine flu virus was considered as its greatest danger as this could have made both
existing flu medication and vaccines ineffective, and could have increased the severity
of the disease, as well.
20.
According to some critical experts, it was precisely this lack of watertight
evidence about the influenza phenomenon which led to the fears of the pandemic being
exaggerated and the subsequent disproportionate response. Apparently, even for
health experts and medical professionals it was difficult to clearly distinguish between
influenza and influenza like illness, which caused an overall impression that the
pandemic was worse than it in fact was. In this respect, Dr Tom Jefferson of the
Cochrane Collaboration19, at a Parliamentary Assembly hearing held in Paris on 29
March 2010, stated that “few (if any) national and international surveillance systems
make the distinction between influenza and influenza-like illness, either because they
do not believe the question is important, because the ‘system’ is not geared up for it or
for other still unclear reasons”. He further noted that only 7-15% of people with flu
symptoms truly have influenza. In other words, vaccination programmes are directed
against what surveillance systems worldwide call “influenza”, but in reality are
influenza-like illness or flu. In advancing this data, he expressed the concern of certain
critical experts as to whether the response to the H1N1 situation was appropriate.
Furthermore, many countries have had difficulties in clearly distinguishing between
patients dying with swine flu (i.e. showing symptoms of swine flu whilst having died of
other pathologies) and patients dying of swine flu (i.e. swine flu being the main lethal
cause), which might have ‘falsified’ some of the statistics on which later public health
decisions were founded. Very recently, Dr Klaus Stoehr, who was until 2007 in charge
of WHO's pandemic preparedness, reinforced doubts about the appropriateness of the
response given to H1N1 influenza by saying: "The pandemic planning I was involved
with was always based on a severe public health event. [...] Moving to Phase 6 meant
that we wanted governments [...] to kick in their plans whether they thought it was
urgent or not". He then further expressed his belief that moving to Phase 6 that early
was, in hindsight, not needed, and that WHO, over the course of summer 2009, had
failed to read the signs about swine flu coming from the southern hemisphere20.
21.
The Assembly fully supports the responsible use of ‘precautionary approaches’
in public policies, as stated in its Recommendation 1787 (2007) on “The precautionary
principle and responsible risk management”. In a direct exchange with WHO
representatives, the rapporteur nevertheless raised the question as to why WHO
maintained the highest alert levels, even when empirical evidence had already shown
that the pandemic turned out to be much milder than initially expected. In reply, Dr
Keiji Fukuda, Special Advisor on Pandemic Influenza to the Director-General, stated on
behalf of WHO that, during a public health emergency, health officials must sometimes
make urgent, often far-reaching decisions in an atmosphere of considerable scientific
uncertainty. He was convinced that it was preferable to see a moderate pandemic with
ample supplies of vaccine rather than a severe pandemic with inadequate supplies of
vaccine and considered the action followed in relation to the H1N1 virus as being
justified21. In his statement made in January 2010, he further added that it was too
early to say whether the pandemic was over and that another significant wave could
still be expected across Europe in the winter or spring.
22.
It is clear to the rapporteur that the proportionality of the response to the
H1N1 influenza needs to be evaluated and that WHO and member states need to
consider this in the context of the review processes that have been set up or are being
set up in the light of the debate on the pandemic. Furthermore, all public health
authorities concerned should critically review their way of dealing with the
precautionary principle, including the communication about its use, given that the
question of what society should do in the face of uncertainty is necessarily a question
of public policy and not only a question of science. In future situations posing a serious
risk to public health, decision-makers should bear in mind that the precautionary

principle can contribute to a general feeling of anxiety and unease in the population
and can fuel the media in what becomes a cycle of fear mongering.
23.
In a situation where uncertainty is coupled with risks for human health and
lives, there is also a danger that public opinion can be manipulated in favour of
particular commercial interests. In addition, it should be recognised that there is a
danger that policy makers are forced to make choices not dictated by the search for
the optimal solution, but rather a solution that would protect them from accusations
(the so-called umbrella phenomenon).22 In the view of the rapporteur it is therefore of
utmost importance that vital decisions regarding public health threats, notably when
placed in a context of uncertainty, are taken in a fully transparent way. Furthermore,
complete information needs to be provided to the public in a manner which allows even
those with little scientific knowledge to follow the arguments in a dispassionate
manner. In this respect, the rapporteur recognises that assessing and communicating
the impact of a virus is difficult and that only in retrospect can one say what is a severe
or mild to moderate level of pandemic. However, in order to avoid what has been
called the “concern bias”, in which anxiety drives reactions to a greater extent than the
disease itself, some commentators have recently called for a more calibrated approach
to emerging infections and the need to reassess both the risk assessment and risk
management strategies23.
Changing the definition of a pandemic
24.
A number of members of the scientific community became concerned when
WHO rapidly moved towards pandemic level 6 at a time when the influenza presented
relatively mild symptoms. This combined with the change in the definition of pandemic
levels just before the declaration of the H1N1 pandemic heightened concerns. As Dr
Wolfgang Wodarg, German epidemiologist and former member of the Assembly,
highlighted at the public hearing on 26 January 2010, the declaration of the current
pandemic was only made possible by changing the definition of a pandemic and by
lowering the threshold for its declaration.
25.
WHO continues to assert that the basic definition of a pandemic was never
changed. Only the description of pandemic alert levels was revised when the document
“Pandemic Influenza Preparedness and Response: A WHO Guidance Document” (new
title) was updated in May 2009. Notwithstanding these assertions, there is clear
evidence that changes were made and that, most importantly, the former criteria of
‘impact and severity’ of an epidemic in terms of the number of infections and deaths
was no longer considered relevant in the updated document24. In other words, the
pandemic could be declared without the need to show that it was likely to be severe in
terms of its impact on the population (for example regarding severity of illness and
death). The definition before 4 May 2009 was worded as follows: “An influenza
pandemic occurs when a new influenza virus appears against which the human
population has no immunity, resulting in epidemics worldwide with enormous numbers
of deaths and illness. With the increase in global transport, as well as urbanization and
overcrowded conditions, epidemics due the new influenza virus are likely to quickly
take hold around the world”, whilst the same definition became the following on WHO’s
website after this date: “A disease epidemic occurs when there are more cases of that
disease than normal. A pandemic is a worldwide epidemic of a disease. An influenza
pandemic may occur when a new influenza virus appears against which the human
population has no immunity …. Pandemics can be either mild or severe in the illness
and death they cause, and the severity of a pandemic can change over the course of
that pandemic”.
26.
Shortly afterwards, WHO spokeswoman Nathalie Boudou justified the change
by saying that the “old” definition was in “error” and had been removed from the WHO
website. She stated that the correct definition was that a "pandemic indicated
outbreaks in at least two of the regions into which WHO divides the world, but has
nothing to do with the severity of the illnesses or the number of deaths”.25 These
subsequent definitions and comments presented at a time when the pandemic was
imminent were confusing for both public health professionals involved and attentive
observers amongst the European public at large.
27.
The rapporteur strongly recommends that further in-depth work be done by all
stakeholders concerned with a view to agreeing on a common definition and description

of what an influenza pandemic is. This should become the central element of clear
international guidelines for national pandemic preparedness planning. He considers
that, even if WHO did not intend to modify the pandemic definition in a way that would
allow for an accelerated announcement of such an event in June 2009, the changes of
relevant disease descriptions and indicators at a time when a major influenza infection
was already approaching was highly inappropriate and carried out in a way which could
be considered as being non-transparent. It also contributed to the doubts raised
concerning undue influence on decision-makers, because all critical observers of the
situation wondered if this untimely change was absolutely necessary and question who
benefited most from it.
Public-private partnership under scrutiny
28.
Public-private partnerships were introduced into the governance system of
WHO following a call in 1993 by the World Health Assembly to mobilise and encourage
the support of all partners in health development, including NGOs and institutions in
the private sector. This substantial change in its working methods had the positive
intention of “mobilising privately funded resources and expertise for the benefit of
public health, whilst giving the commercial sector the opportunity to attract new
investors and establish new markets through an improved corporate image”. However,
WHO successively developed institutional safeguards to counterbalance potential risks
of public-private partnerships, and published its guidelines on working with the private
sector to achieve health outcomes in 2000. When it introduced mechanisms intended
to safeguard its integrity, WHO found itself directly at the centre of a debate on the
appropriateness of public-private co-operation. At the time, the precautions taken were
welcomed by some critics but many saw them as inadequate both in substance and
process. 26
29.
The rapporteur believes that, despite greater awareness of the risks of publicprivate partnership today and the development of routine safeguards against conflicts
of interests within WHO governance bodies, continued attention should be given to this
issue. In a world characterised by a high level of access to information technologies
where lobbying activities and relevant networks of interest groups are increasingly
internationalised and professionalised, the problem of possible conflicts of interest of
health experts is more topical than ever. It is precisely in this context that the
Assembly adopted its Recommendation 1908 (2010) on “Lobbying in a democratic
society” in which it stated that unregulated or secret lobbying may be a danger and can
undermine democratic principles and good governance. With regard to the public
health sector, the rapporteur is notably concerned by the systematic recruitment of socalled “key opinion leaders” by specific “image and communication agencies” in the
pharmaceutical industry27.
30.
For the rapporteur, the possibility that representatives of the pharmaceutical
industry may have directly influenced public decisions and recommendations made with
regard to the H1N1 influenza remains one of the central issues of the ongoing debate,
which has been further nurtured by the revelations of the British Medical Journal (BMJ)
on 4 June 201028. Amongst the factors leading to the suspicion of undue influence were
the early measures taken on contractual arrangements for vaccine delivery between
member states and pharmaceutical companies, as well as the enormous profits that
companies were able to make as a result of the pandemic. The main suspicion,
however, arises with regard to the issue of whether members of WHO advisory bodies
have professional links to pharmaceutical groups, bringing into question the neutrality
of their advice. Unfortunately, due to WHO’s refusal to release the names and
declarations of interest of persons concerned, any current research on the matter
depends entirely on the results of investigative journalism29.
31.
Neither of the WHO advisory bodies, SAGE nor Emergency Committee, have
any executive or regulatory functions. Their members are appointed by the DirectorGeneral of WHO according to the so-called IHR Expert Roster and in compliance with
the WHO Advisory Panel Regulations. The Organization admits that, when reaching out
to a broad group of experts and interest groups, there is always a potential risk of
conflicts of interest in the advice given, but that possible conflicts of interest are
countered by a number of routine safeguards. According to WHO, transparency is
ensured by declarations of interest in which external experts present all their
professional and financial interests, including funding received from pharmaceutical

companies, consultancies or other forms of involvement in relevant commercial
activities.
32.
According to senior WHO officers, biased recommendations are prevented by
only allowing those experts who have no perceived or real conflicts of interest to make
recommendations. Finally, the relative weight of those who declare a conflict of interest
is also an element to be taken into account in WHO’s view: if a conflict of interest
appears regarding a person who could otherwise give valuable input, the person
concerned is only allowed to participate in the general exchange of views and
communication. Although this approach reveals a certain degree of awareness of this
sensitive issue, the rapporteur is not convinced that it represents a sufficient safeguard
against possible conflicts of interests, and thus undue influence and bias.
33.
The main focus of criticism is the Emergency Committee directly advising the
Director-General on the H1N1 pandemic. This Committee has met a total of eight times
since the outbreak of the pandemic (meetings held between April 2009 and May 2010).
After reviewing available data on the current situation, Committee members identified
a number of gaps in knowledge about the clinical features, epidemiology and virology
of reported cases and the appropriate responses. The Committee advised that answers
to several specific questions were needed to facilitate its work, but generally agreed
that the current situation constituted a public health emergency of international
concern.
34.
Although critical voices from various countries and the Assembly itself30 have
on several occasions called for the list of experts and their respective declarations of
interest to be published, WHO has failed to provide this information. The Organization
continues to hold back on releasing further information on the interests of experts,
justifying this position by the need to protect experts’ privacy and to prevent them
from coming under extreme pressure from certain private companies or interest
groups. The rapporteur is very concerned by this attitude and remains convinced that it
is entirely justified to require full transparency with regard to the profiles of experts
whose recommendations have far-reaching consequences for the public health sector
and the health and well-being of Europeans.
35.
The rapporteur would like to highlight that some degree of understanding of
the doubts concerning the neutrality of advice could be found even within WHO itself.
The Organization recently acknowledged that: “Adjusting public perceptions to suit a
far less lethal virus has been problematic. Given the discrepancy between what was
expected and what has happened, a search for ulterior motives on the part of WHO and
its scientific advisors is understandable though without justification”31. At the same
time, WHO stated more than once that it considered existing mechanisms to be
satisfactory, but declared its intention to respond to allegations of undeclared conflicts
of interest, which it claimed to take very seriously. As early as January 2010, WHO
announced its intention to launch a review of the way in which the ongoing pandemic
was handled, including an evaluation of its own performance, with the participation of
external experts and with a view to reviewing existing International Health Regulations
(IHR).
36.
As announced in January 201032, an internal review process was launched by
WHO through the Review Committee on the Functioning of the International Health
Regulations (2005) in relation to Pandemic (H1N1) 2009. It met for the first time on
12-14 April 2010 in Geneva. According to its first report, the Committee pursued a
threefold objective (1) to assess the IHR in relation to the current pandemic, (2) to
review the scope, appropriateness, effectiveness and responsiveness of global action as
well as the role of the WHO Secretariat and (3) to identify and review the major
lessons learnt from the global response to the current pandemic.
37.
The rapporteur commends this critical and self-critical approach taken by WHO
regarding the H1N1 pandemic and the current loss of confidence amongst Europeans,
both members of the public and decision-makers. The rapporteur requests that the
critical issues raised in the present report should be taken up comprehensively during
the review process which is under way. He strongly advises WHO and other institutions
concerned to explicitly open up their policy guidance process to experts with diverse or
contrary views in order to avoid what could be referred to as “group think”. In this
respect, the rapporteur very much welcomes the fact that the WHO Review Committee,

which has just taken up its work, is chaired by Professor Harvey V. Fineberg, President
of the Institute of Medicine of Washington D.C. (USA), who stated in 1978: “In a swine
flu case when evidence is thin […] it is not only the assumptions but appraisal of their
scientific quality that top decision-makers need. Panels tend toward ‘group think’ and
over-selling, tendencies nurtured by long-standing interchanges and intimacy, as in the
influenza fraternity. Other competent scientists, who do not share their group identity
or vested interests, should be able to appraise the scientific logic applied to available
evidence”33. However, the rapporteur is very concerned that it appears that some of
the members of the Review Committee are also members of the Emergency Committee
whose actions they are meant to review (in particular the Chair of the latter)34.
Communication and dialogue on sensitive health issues
38.
In addition to the substantial advice given by WHO and other major
stakeholders, and to the way in which it was prepared, a critical view is also justified
regarding the – sometimes ambiguous - way in which issues related to the H1N1
pandemic were communicated to national governments and the European public at
large. In this respect, the rapporteur wishes to highlight the regular overstatement of
the pandemic’s expected outcome in terms of infections and deaths which nourished
increasing uncertainty and fears amongst Europeans. A review is also necessary of the
media’s role in fuelling fear and how WHO and how national authorities should handle
communications in the future, in particular when applying the precautionary principle.
39.
WHO itself continues to assert that it has consistently evaluated the impact of
the current influenza pandemic as moderate, reminding the medical community, public
and media that the overwhelming majority of patients experience mild influenza-like
illness and recover fully within a week, even without any form of medical treatment35.
Most people, however, expected more dramatic consequences, not least because in
spring 2009, the approaching swine flu was repeatedly compared to previous infectious
diseases, notably the avian flu and SARS in more recent years, but also the Spanish flu
of 1918. For some experts, such as Professor Keil, epidemiologist and Director of WHO
Collaborating Centre on epidemiology of the University of Münster (Germany) who was
heard at the public hearing of 26 January 2010, the comparison with the ‘Spanish flu’
of 1918 was generally inappropriate given that empirical figures were far from
comparable. The ‘Spanish flu’ took place in the historical context of World War One
where infections were easily transmitted by soldiers, many of whom were
undernourished and without medication considered as basic today, such as penicillin. In
reacting to this, WHO stated that reference to former health events should be taken as
a positive sign: the Organization for example pointed to the success in limiting the
spread of SARS as a major public health victory36.
40.
In recent debates, WHO furthermore declared itself aware that preparing and
communicating information on complex public health matters had become a major
challenge in the globalised context of the 21st century, in view of the fact that
information is more decentralised and expectations of the population are much higher.
There are now not only traditional news services but also blog sites, email and a
number of other sources of information which have to be taken into account. The
rapporteur considers that much more will need to be done in the future to improve
dialogue and communication on sensitive public health matters at international,
European and national levels. As Gerd Gigerenzer, Director of the Centre for Adaptive
Behaviour and Cognition at the Max Planck Institute in Germany said: “The problem is
not so much that communicating uncertainty is difficult, but that uncertainty was not
communicated.”37
b.

The role of the pharmaceutical industry

41.
A number of vaccine manufacturers are involved with the production of H1N1
vaccines at international level38. At European level the vaccines - Focetria of Novartis,
Pandemrix of GlaxoSmithKline, Celvapan of Baxter International as well as Panenza of
Sanofi-Pasteur - were used during the H1N1 pandemic. These companies are organised
in the European Vaccine Manufacturers Group EVM belonging to the European
Federation of Pharmaceutical Industries and Associations (EFPIA).
42.
Through EVM, the pharmaceutical industry was represented in the public
hearing on 26 January 2010. According to EVM, the need for action generated by the

declaration of the pandemic in summer 2009 demanded an unprecedented level of
collaboration involving WHO, national governments, health authorities, regulatory
agencies, scientists, healthcare professionals and private sector companies, in order to
deliver the appropriate countermeasures.39
43.
The role of the pharmaceutical industry is closely linked to the issue of
prevailing procedures for drug evaluation and authorisation and the degree of
transparency characterising them. According to the information given to the
rapporteur, all vaccines used during the pandemic were authorised according to the
formal procedure followed by the European Medicines Agency (EMEA) although not all
of them were clinically tested on vulnerable persons such as children40. In its official
statements, the Agency asserted that, despite the short delays within which vaccines
were authorised, they had been sufficiently tested, along with the adjuvants used41.
Whether or not there was sufficient testing remains highly controversial within the
medical community. There is, however, evidence that at least one vaccine without
adjuvants made by Sanofi-Pasteur (Panenza) was treated differently and was able to
receive national authorisation in some countries, such as France, without passing
through some of the rigid European procedures42. Without wishing to take a definitive
stance on this highly specific question here, the rapporteur considers it entirely justified
to ask whether scientific evidence was sufficient to remove any remaining doubts about
the relevant products.
44.
The most crucial question in this respect concerns the possible risks taken with
regard to the health of those persons taking the vaccines and anti-flu medication, and
notably the most vulnerable groups (such as children, pregnant women or chronically
ill persons). Some critical experts had already pointed out that side-effects or
effectiveness of vaccines and antiviral medication (such as Tamiflu or Relenza) had not
been sufficiently tested before their commercialisation. This notably concerned some of
the vaccines which were developed by using specific patented adjuvants or breeding
layers for the virus antigen to come. The fact that only patented products received
authorisation was the reason why the vaccines could be monopolised by a few
companies and sold at much higher prices than seasonal vaccines, which are
traditionally produced in chicken eggs and could have been provided much faster by
many laboratories all over the world using non-patented procedures.43 A few months
after the declaration of the pandemic, even the European Medicines Agency pointed out
that “only limited data on the safety and immunogenicity of influenza A(H1N1)v
vaccines will be available when member states start to use the vaccines. In addition,
due to the possible mutation of the virus, the effectiveness of the vaccines will need to
be followed.”44
45.
Critical experts also wondered about the general need of developing a special
vaccine aimed at H1N1 influenza. Given that new flu virus variations are detected
almost every year, the virus could possibly have been treated by flu vaccines in stock,
instead of having to produce a special product in a very short time, thus speeding up
some of the authorisation procedures as described above. Finally, and closely linked to
the above health aspects, the rapporteur considers it important to raise the question of
whether national governments were well advised by health authorities before
purchasing great quantities of vaccines authorised in fast-track procedures. This
particularly concerns the initial advice that double doses were necessary. For the
rapporteur it is clear that the way of dealing with vaccines through accelerated
evaluation and authorisation procedures reinforced the exposure of national
governments to the possible pressure of pharmaceutical groups and the suspicion of
undue influence on public health decisions.
46.
Another factor which nurtured suspicions about undue influence was that the
pharmaceutical companies had a strong vested interest in the declaration of a
pandemic and subsequent vaccination campaigns. This interest arose partly from early
contractual arrangements regarding any new influenza pandemic (some were
concluded between member states and pharmaceutical groups in the period 2006/2007
just after the avian flu scare). Various European countries signed so-called “sleeping
contracts” with large pharmaceutical groups which were supposed to take effect on the
declaration of a pandemic by WHO45. Whilst this anticipation of a major public health
event by governments and pharmaceutical groups could be generally welcomed, the
rapporteur would like to point out that there is evidence of doubtful commercial
practices followed by some industrial groups. The rapporteur refers in particular to

pressure exerted on national governments to activate “sleeping contracts” after very
short delays of reflection (using the argument of “first come – first served”) and the
attempt to transfer the main responsibility for side-effects of vaccines to the
governments themselves (see the experience of Poland described later). Following
these suspicions, and in light of the major impacts on public health budgets all over
Europe, the rapporteur welcomes the willingness of pharmaceutical groups to step back
from contractual arrangements made with national governments and allow them to opt
out of some of the orders not yet delivered.
47.
The strong commercial interests in the pandemic and vaccination campaigns
were further illustrated by the high levels of profit that pharmaceutical companies were
able to make. According to estimations by the international investment bank JP
Morgan, the overall sales of H1N1 vaccines in 2009 were expected to represent
between 7 and 10 billion dollars for pharmaceutical companies producing vaccines.
According to figures presented by Sanofi-Aventis at the beginning of 2010, the group
registered a “record year” of anti-flu vaccines sales for a total amount of 7.8 billion
Euros (+11%).46 As such, and from the point of view of the market economy, justified
commercial interests cannot be generally criticised. The rapporteur would, however,
like to raise the question as to whether it was justified to sell H1N1 vaccines to national
governments at prices seemingly up to 2 to 3 times higher than those for the usual
seasonal influenza by primarily using patented adjuvants, and thus making
exaggeratedly high profits from a declared public health emergency?
48.
Concluding on the current role of the pharmaceutical industry, the rapporteur
considers that – whilst public authorities need to further strengthen safeguards with
regard to excluding any conflicts of interest, and while there was a general willingness
of pharmaceutical groups to participate in a dialogue – additional efforts are needed
from industrial players to prove that they are not exerting undue influence on public
health decisions and drawing unreasonably high returns from emergency situations. In
the same way that confidence needs to be rebuilt in public health action, it is necessary
to consolidate trust in science and medicine by all possible means, including the
involvement of a broad range of scientific expertise. The case of the H1N1 pandemic
also raises challenging questions about the system by which drugs are evaluated,
regulated and promoted. When vast quantities of public money and large amounts of
public trust are placed in drugs, the full data must be accessible for scrutiny by the
scientific community47.
c.

The role of member states and their health authorities

49.
Member states have to address a complex set of issues related to the H1N1
pandemic which can be summarised in two central questions: Firstly, were they well
advised regarding pandemic preparedness strategies and, secondly, did they act in a
responsible manner with a view to their citizens’ health and well-being? For this report
a number of national reactions were examined. The rapporteur does not intend to
judge, on behalf of all Council of Europe member states, if the matter was dealt with
appropriately or not. It will be up to each member state to address the questions
highlighted in the current report and draw its own conclusions.
50.
Just as different members of the medical community are divided in their
positions, Council of Europe member states showed different reactions to the H1N1
pandemic, ranging from very reserved attitudes and low-profile vaccination campaigns
(Poland), to highly pro-active approaches to pandemic preparedness (United Kingdom
and France). However, lingering concerns and the lack of scientific evidence about the
effectiveness and possible side-effects of vaccines led to a clear decrease in the
demand for the new vaccine amongst the population of many countries. Thus, in
December 2009, many countries such as Germany, France, the United Kingdom, Italy
and Ireland reported that only about 10% of the population had been vaccinated. It
was this low level of demand which finally led to the perception of public budgets
having been wasted on the H1N1 pandemic, given that great quantities of vaccines
ordered by many governments were never used.
51.
In order to better understand some of the decisions taken at national level and
their motivations, the rapporteur took a closer look at the way in which the pandemic
was handled in the United Kingdom, France and Poland. These countries showed some
of the most extreme reactions to the announcement of the pandemic in June 2009. The

British Department of Health initially announced that approximately 65 000 deaths
were to be expected. At the beginning of 2010, this estimate was downgraded to only
1 000 fatalities. By January 2010, fewer than 5 000 persons had been registered as
having caught the disease and 360 deaths had been noted. In March 2010, the
rapporteur had the occasion to meet with Gillian Merron, then Minister of State for
Public Health, in order to discuss the handling of the H1N1 influenza at national level,
and was informed that an independent internal investigation by the Cabinet Office was
underway, the results of which would be reported after June 2010.
52.
The figures available for France illustrate very well the extent to which the
H1N1 pandemic was overstated and the consequences for the public health budget:
312 people died of influenza (up to April 2010), whilst 1 334 cases of serious infection
were registered since the beginning of the pandemic according to the National Institute
for the monitoring of health issues (“Institut national de veille sanitaire”). In the light
of the actual development of the H1N1 pandemic, the French government managed to
cancel orders for 50 million doses of vaccine, out of a total of 94 million initially
ordered. Vaccines were sold on to some other countries, however France was left with
millions of unnecessary doses as only 5.7 million people were vaccinated by March
2010. The final French public health bill for vaccines amounted to 365 million Euros and
a stock of 25 million doses of vaccine whose shelf life will expire at the end of 201048.
The rapporteur considers that with hindsight it can be concluded that France is not in
an enviable position. France, however, is not alone in this situation.
53.
In the light of this evidence, some of the critical issues raised in this report
have now been addressed at the national level in France. Critical observers of the
pandemic in France have openly questioned the neutrality of “independent experts”
present in some of the official national bodies, such as the Committee for fighting the
influenza (“Comité de lutte contre la grippe”)49. The National Assembly and the Senate
have taken a proactive approach by organising a public hearing on the possible action
by researchers and public authorities with regard to the H1N1 influenza through the
Parliamentary office for the evaluation of scientific and technological choices50. The
French Senate launched an inquiry committee on the role of pharmaceutical companies
in the handling of the H1N1 influenza by the French Government, which started its
investigations in February 2010 with a view to presenting a report in August 2010. The
National Assembly has launched a parallel procedure through its “Investigation
committee on the way in which the vaccination campaign against Influenza A (H1N1)
was planned, explained and handled“. The committee is due to present its report on 13
July 2010.
54.
Certain member states did not rush into taking action following the
announcement of the pandemic. Poland, for example, is one of the few countries in
Europe not to have purchased large quantities of vaccines due to safety fears and
distrust of the pharmaceutical companies producing them. At the public hearing
organised by the Assembly in Paris on 29 March 2010, the Polish Health Minister, Ms
Ewa Kopacz, described the Polish approach to managing the pandemic. She explained
that it was undertaken in close collaboration with the European Centre for Disease
Control and Prevention (ECDC) and national centres. It included a thorough analysis
taking care to combat panic and general social unease by the public at large. The Polish
Flu Pandemic Committee defined a high risk group of 2 million persons and set aside
resources to buy appropriate numbers of vaccines. However, the Minister considered
that the conditions proposed by the pharmaceutical companies for the purchase of
vaccines were unacceptable. Vaccines were to be purchased only by the government
(not marketed to private individuals), and the government was asked to take full
responsibility for all undesirable side effects (the threat of which seemed real according
to the Eudravigilence system). Furthermore, the vaccines were offered at up to 2 to 3
times the price of vaccines used against seasonal influenza. As the Polish Minister
herself emphasised during the public hearing in March 2010, she took the responsibility
– as a politician and medical doctor - not to accept these conditions and avoid
becoming hostage to private interest groups or being obliged to take major decisions
resulting from alarmist announcements.
55.
Following some of the widely debated criticisms of the handling of the H1N1
crisis, many member states have de-intensified their vaccination campaigns and
managed to divest themselves of the vaccines already purchased but not used, either
by opting out of arrangements with pharmaceutical companies or by re-selling part of

their stocks of vaccines to third parties in order to limit the impact on public health
budgets under strain during the economic crisis. The rapporteur recognises that the
damage to public health budgets has been slightly limited in this way. He is
nevertheless concerned by the distortion of public health priorities during the course of
the last year and the enormous sums of money which could have been used for many
other, often more urgent, health issues. He is convinced that the Assembly should
strongly encourage Council of Europe member states in the future to take a more
critical stand when it comes to future pandemic warnings. Moreover, they should
themselves review the way in which the H1N1 pandemic was handled at national level
by following the examples of countries that have already started to review their
handling of the pandemic (such as France).
56.
The Assembly should encourage member states to closely follow relevant
review processes recently launched within WHO and European institutions involved in
public health matters, in order to ensure that their voices may have more impact in
future pandemic situations than seems to have been the case in the current H1N1
pandemic. There is strong evidence that some governments, including China, Great
Britain, Japan and a dozen other countries, at some stage of the H1N1 pandemic,
urged WHO not to use the proposed new definition of a “pandemic” and "be very
cautious about declaring the arrival of a swine flu pandemic, fearing that a premature
announcement could cause worldwide panic and confusion." In reply to their doubts,
WHO said “it would certainly look at [this issue] very closely” just before declaring the
pandemic on 11 June 2009.51
d.

The role of European Union bodies

57.
The specific role of European Union bodies involved in health issues has not
been researched in detail for the purpose of the current report as the rapporteur
wished to focus on the ‘triangle of action’ represented by WHO, national governments
and the pharmaceutical industry. Their role in the H1N1 pandemic may therefore be
mentioned as an element of background information allowing for a comprehensive
understanding of the current situation and review processes just starting.
58.
The central European body in charge of the Europe-wide authorisation of new
medical products, including vaccines, is the European Medicines Agency (EMEA).
Monitoring the progress of the H1N1 pandemic at European level has been and
continues to be ensured through the European Centre for Disease Control and
Prevention (ECDC). It has provided daily updates on the situation up to the beginning
of 2010. Notwithstanding that ECDC considered that the pandemic was far from over
and that considerable uncertainties remained, their Public Health Event Strategy Team
(PST) decided to downgrade their crisis management activities in January 2010, thus
ending the publication of the daily updates. After this date, the ECDC has nevertheless
continued its work relating to the H1N1 pandemic under a reinforced general influenza
programme52. The mission of the ECDC, established in 2005 and seated in
Stockholm/Sweden, is to identify, assess and communicate current and emerging
threats to human health posed by infectious diseases in partnership with national
health protection bodies across Europe and by associating health experts throughout
Europe. As with WHO, the ECDC relies on internal advisory bodies. The names and
declarations of interest of experts on these bodies have still not been released either.
59.
The European Commission is currently evaluating the management of the
H1N1 influenza by its own institutions as well as by European Union member states in
the run-up to a planned Belgian Presidency and European Commission conference at
the beginning of July 2010. Furthermore, the European Commission announced, on 9
March 2010, the launch of new research projects on influenza. Four collaborative
research projects have been shortlisted for funding. They involve 52 research institutes
and small and medium enterprises from 18 European countries and 3 international
partners (Israel, China and the United States).
60.
Finally, an initiative to launch a comprehensive investigation process on the
handling of the H1N1 pandemic by European institutions was undertaken within the
European Parliament by Michele Rivasi, member of the Group of Greens/European Free
Alliance. The European Parliament decided on 20 May 2010 not to set up an
investigation committee, leaving further follow-up open at this stage. The rapporteur
has collaborated closely with Ms Rivasi who participated in the second hearing of the

Social, Health and Family Affairs Committee on 29 March 2010. The rapporteur hopes
that this fruitful collaboration between the European Parliament and the Parliamentary
Assembly can be pursued in the future on other public health issues of European
concern.
61.
Although certain critical issues will have to be reviewed at European level (such
as possible conflicts of interest of health experts and the transparency and outcomes of
certain fast-track authorisation procedures for vaccines), the rapporteur generally
welcomes the realistic approach taken on the pandemic by European institutions
involved in public health matters who downgraded their alert systems at the beginning
of 2010, as well as the critical review processes recently launched. He hopes that the
European Commission will furthermore follow and contribute to the activities and
debates on good governance in the public health sector of the Council of Europe level,
including at the level of the Assembly.
4.

Conclusions - Recommendations

62.
In concluding the present report, the rapporteur remains greatly concerned
with the way in which the 2009/2010 H1N1 influenza pandemic was handled and in
particular with the lack of transparency of some of the decisions taken. He considers
that the debates and discussions held in the past months, including those in the
framework of the Assembly, have already helped public health authorities analyse
some of the issues being faced and given them encouragement to carry out their own
review processes.
63.
For the rapporteur, the main concerns regarding the current H1N1 influenza
include the proportionality of the response given to the public health threat of H1N1,
the transparency of relevant decision-making processes, including the possibility of
undue influence by the pharmaceutical industry and the way in which the pandemic,
and the use of the precautionary principle, were communicated to member states’
governments and to the European public at large, also by the media.
64.
The rapporteur considers that some of the outcomes of the pandemic, as
illustrated in this report, have been dramatic: distortion of priorities of public health
services all over Europe, waste of huge sums of public money, provocation of
unjustified fear amongst Europeans, creation of health risks through vaccines and
medications which might not have been sufficiently tested before being authorised in
fast-track procedures are all examples of these outcomes. From the rapporteur’s
perspective, these results need to be critically examined by public health authorities at
all levels with a view to rebuilding public confidence in their decisions. Public health
authorities need to be better prepared for the next infectious disease of pandemic
scope, which might be of greater severity.
65.
Serious doubts unfortunately remain concerning the transparency of decisionmaking processes relating to the H1N1 pandemic. After having analysed relevant
processes, the rapporteur is alarmed by the inappropriate timing and method of
changing essential definitions related to pandemics as well as the possible influence of
pharmaceutical groups on some of the central decisions taken. The rapporteur
continues to be very concerned by the lack of transparency regarding the identity of
experts whose recommendations have had a major impact on public health budgets
and people’s health. He considers that the right of 800 million Europeans in Council of
Europe member states to be fully informed should prevail over the right of a relatively
small number of experts to privacy.
66.
Suspicion of undue influence and pressure put on national authorities by the
pharmaceutical industry has been reinforced by other factors, such as the character of
contractual arrangements concluded between governments and pharmaceutical groups.
Reports from several European countries indicate that there was pressure exerted on
national governments to speed up the conclusion of major contracts, that dubious
practices were followed concerning prices of vaccines, which were not available under
normal market conditions, and that there were attempts to transfer liability for
vaccines and medication, which might not have been tested sufficiently, to national
governments. The rapporteur considers that these incidences were most alarming. He
encourages greater co-operation between national governments in order for them to be

able to take coherent and strong stands when negotiating with large pharmaceutical
groups in the future.
67.
Finally, the rapporteur is very concerned about the way in which the
information on the pandemic was communicated by WHO and national authorities to
the public, the role of the media in this and the fears that this generated amongst the
public. The rapporteur recommends that a thorough review should be undertaken to
ensure that coherent and sensitive communication strategies are prepared and
followed in the future by all public health authorities whenever the next major situation
arises which poses a serious threat to public health.
68.
With regard to previous public health scares (avian flu, SARS, etc.), the
rapporteur is convinced that there is a real danger of now having cried ‘wolf’ so often
that the public will not take appropriate notice anymore when the next infectious
disease occurs. Many people might then decide not to get vaccinated and put their own
health and lives, and indirectly those of others, at risk. Therefore, certain immediate
efforts are required with a view to rebuilding public confidence in decisions and
recommendations made by WHO and other public authorities concerned.
69.
Conclusions from the handling of the H1N1 pandemic should, however, be
drawn at different levels. With regard to immediate action to be taken, the Assembly
should request that WHO and European institutions concerned, share some essential
information, notably by publishing the names and declarations of interest of experts
present on relevant advisory bodies who have had a direct influence on public health
recommendations taken.
70. In order to provide substantial input to ongoing review processes, the Assembly
should address all major stakeholders concerned, including WHO, European Union
bodies dealing with health matters, and also national governments or parliaments. The
Assembly should invite them to review their governance structures in the public health
sector, agree on common definitions related to public health (such as pandemics), to
revise existing guidelines for working with the private sector or prepare such guidelines
where they do not exist and, finally, to entirely revise their communication strategies
relating to sensitive public health issues. The Assembly should further ask for
maximum transparency in all work undertaken.
71.
Member states should be explicitly invited to follow-up on the conclusions of
internal review processes undertaken within international and European institutions in
order to make sure that they take into account all relevant recommendations including
those of the Assembly. They should furthermore be invited to start relevant review
processes at national level where they have not done so, and national parliaments
should be involved in these processes.
72.
The Assembly should also call upon the pharmaceutical industry to be aware of
their corporate social responsibility with regard to major public health matters and to
act in the most transparent manner possible. Beyond their openness to participate in
the public debates during recent months and directly respond to questions and criticism
raised, international industrial groups should be ready to critically revise their own
rules and functioning regarding co-operation with the public sector and their role in
public health emergencies. Just as the World Health Assembly did in 1993 by calling for
the introduction of public-private partnerships into WHO mechanisms, the rapporteur
fully recognises the fact that the highly specialised knowledge in industrial companies
makes them an indispensable partner for public health authorities. This should,
however, not empower them to put public health authorities under pressure and
commercialise their products with a view to making excessive profits in emergency
conditions.
73.
There are many organisations and institutions at international, European and
national level which have been concerned by pandemic preparedness planning and the
implementation of subsequent vaccination strategies during the H1N1 pandemic. At the
level of the Council of Europe, good governance in the public health sector is addressed
at a general level through intergovernmental co-operation activities related to the
development of an ethical European health policy. In this respect, the rapporteur
welcomes the recent adoption of Recommendation CM/Rec(2010)6 of the Committee of
Ministers to member states on good governance in health systems which could become

a valuable contribution to the creation of truly transparent public health systems in
Europe.
74.
The specific contribution of the Assembly in the current situation has been and
will be to provide a European platform where issues relating to democratic
accountability and transparency of public decision-making processes in the health
sector have been and will continue to be debated. In addition to its contribution
regarding the topical issue of the H1N1 Pandemic, the Assembly should organise more
regular debates on good governance in the health sector with major international and
European stakeholders, notably WHO and European institutions responsible for health
matters.
Appendix I
The handling of the H1N1 pandemic: more transparency needed Visit to the
World Health Organization, Geneva, 15 April 2010
Written responses by WHO to the questions presented by the rapporteur:
A.
SEASONAL AND PANDEMIC INFLUENZA: THE H1N1 INFLUENZA
OUTBREAK
1. Please provide an overview of the definition of "influenza pandemic" and
any changes in the definition over the last 5 years? What was the reason for
the change of the pandemic influenza definition (May 2009) and who was
responsible for changing this?
A pandemic of disease refers to the worldwide spread of an epidemic disease53. An
example of a pandemic that is not related to influenza is the emergence and spread of
HIV. A pandemic of influenza refers specifically to the emergence and worldwide spread
of an influenza virus that is "new" in the sense that it is immunologically "novel" for
much of the world's population.
In 1999, WHO produced its first pandemic preparedness guideline for countries based
on the input from global experts. This document was updated in 2005 and 2009 to
incorporate ongoing changes in scientific knowledge and concepts and public health
experience. These are the guidelines that contain WHO's pandemic phase definitions
provided to countries to assist them in national planning efforts.
The 1999 document is entitled: "Influenza Pandemic Preparedness Plan: The Role of
WHO and Guidelines for National and Regional Planning (WHO/CDS/CSR/EDC/99.1).
On page 14, this document indicates "The Pandemic will be declared when the new
virus sub-type has been shown to cause several outbreaks in at least one country, and
to have spread to other countries, with consistent disease patterns indicating that
serious morbidity and mortality is likely in at least one segment of the population.
Onset shall be defined as that point in time when WHO has confirmed that a virus with
a new haemagglutinin sub-type compared to recent epidemic strains is beginning to
spread from one or more initial foci. Depending on the amount of early warning, this
phase may or may not have been preceded by the above-described series of increasing
levels of preparedness." The same wording is used in Table 1 on page 19. Explicitly,
severity is not stated as a requirement.
The 2005 document is entitled: "WHO global influenza preparedness plan: The role of
WHO and recommendations for national measures before and during pandemics”. On
page 1, in the Executive Summary, some reasons for the update are articulated -"This new plan addresses the possibility of a prolonged existence of an influenza virus
of pandemic potential, such as the H5N1 influenza virus subtype in poultry flocks in
Asia which persisted from 2003 onwards." On page 2, in the Table of New Phases, it
states that the pandemic phase is defined by: "increased and sustained transmission in
general population." In footnote "b," which pertain to phases 3, 4, and 5, it states that
these phases are "based on an assessment of the risk of a pandemic. Various factors
and their relative importance according to current scientific knowledge may be
considered. Factors may include rate of transmission, geographical location and spread,
severity of illness, presence of genes from human strains (if derived from an animal

strain), and / or other scientific parameters." In other words, many potential factors
may be considered. Explicitly severity was not stated as a requirement.
The 2009 document is entitled "Pandemic Influenza Preparedness and Response: A
WHO Guidance Document." In the acknowledgements, this work is ascribed to more
than 135 experts along with more than 90 WHO staff. On page 3, the Forward states
"The information and recommendations in this guidance is the product of expert
opinion, derived from several international consultations which included examination of
available information and modelling studies, input from public health experts on
lessons learned from SARS and both animal and human influenza responses, and
consolidation of recommendations in existing WHO guidance. This guidance was
subject to an extensive public review." On page 8, the Executive Summary covers
reasons for the update including to "more accurately reflect pandemic risk and the
epidemiological situation based upon observable phenomena." On page 11, Table 1
states that Phase 6 is described by: "in addition to the criteria defined in Phase 5, the
same virus has caused sustained community level outbreaks in at least one other
country in another WHO region."
Throughout, WHO has not sought to define or redefine "pandemic". WHO has provided
descriptions of pandemics based on historical observations. WHO has however set out
a phased approach to pandemic response, which has included definitions of pandemic
phases
2. Please explain how the 2009 outbreak of H1N1 meets the definition of a
pandemic, while the annual worldwide circulation and mutation of seasonal
influenza viruses do not?
The pandemic H1N1 virus was considered "new" because it contained a constellation of
genes derived from animal influenza viruses, and because antigenic testing indicated
that antibodies to existing human influenza H1N1 viruses did not react with the new
virus, indicating the virus would be immunologically novel for most or many people.
This constellation of genes had never been seen before in an influenza virus infectious
for humans. The rapid and well documented global spread of this virus was associated
with unusual epidemiological disease patterns such as extensive disease activity in
many countries during summer months. Infection was also associated with an unusual
disease pattern with higher levels of death and serious illness observed in young
people, many of whom were healthy.
By contrast, seasonal human influenza epidemics are characterized by variants of well
known viruses that generally have epidemiological and disease patterns different from
those associated with the H1N1 pandemic virus.
More recent analyses have shown that the haemagglutinin of this H1N1 virus (the key
determinant of immunogenicity) is probably derived from that in the 1918 pandemic
virus. Thus, the vast majority of the human population will not have pre-existing
immunity to this virus, and will therefore be susceptible to infection.
The spread of the pandemic (H1N1) 2009 virus clearly has caused a global influenza
pandemic.
3. Please explain why the number of deaths is no longer taken into account in
the definition of an "influenza pandemic" and whether this might change
again?
WHO never specified any number of deaths as part of any "pandemic phase definitions"
-- see above documentation. But WHO has pointed out that the impact of pandemics is
variable and has been very high in some past pandemics.
4. WHO has in the past said that pandemics cause "enormous numbers of
deaths and illness". However, the last two influenza pandemics are said to
have occurred in 1957 and 1968, but among those people who lived through
them, few people even knew they occurred. Even fewer recall the outbreak of
novel "Russian flu" virus in 1977. Similarly, SARS infected less than 8000
people in a world of 6 billion. It would therefore appear that pandemics can

be mild or strong. In what ways did the WHO's pandemic plan anticipate and
prepare for the possibility of both mild and serious forms of pandemics?
In all WHO pandemic preparedness and response documents it was anticipated that the
next pandemic could be of varying levels of severity. The estimated mortality of
individual influenza pandemics in the 20th century has ranged from approximately one
million in 1968-69 to over 40 million in 1918-1919. The limitation of SARS is
considered a major public health victory and one of the watershed events in modern
public health that demonstrated that global coordination can halt the spread of a newly
emerging disease. All versions (1999, 2005, 2009) of the WHO pandemic preparedness
guidelines anticipated the possibility that the range of impact could be wide.
5. Following laboratory tests, researchers in Mexico reported that only 11% of
"swine flu" cases in that country's outbreak were found to be influenza. This
proportion is the same as in normal seasons, where the vast majority of
influenza-like illnesses cannot be linked to influenza. Given this, why has
WHO emphasized vaccines and antivirals, which only work for influenza, to
combat epidemics which seem to be caused by a large cocktail of all sorts of
viruses?
In responding to the H1N1 pandemic, WHO has emphasized the use of effective
methods to reduce pandemic infections and disease including communications, so
called non-pharmacological interventions and pharmacological methods such as
vaccines and antiviral drugs. This is in keeping with how many other infectious diseases
are approached. Vaccines are used to reduce the number of infections or serious
disease. Antiviral drugs are used to treat infections, but can also be used for
prophylaxis against infection in certain situations. Among cases of influenza-like illness,
the percentage of such cases attributable to influenza, or other pathogens, will vary
depending on the time of year and circumstances. This is a very basic characteristic of
the epidemiology of respiratory diseases and influenza. Other surveillance data from
elsewhere indicate that the proportion of pandemic (H1N1) 2009 viruses isolated from
patients suffering from influenza-like illness was up to 70 %.
WHO recommended use of influenza antiviral drugs and vaccines to reduce serious
illnesses and to save lives. Thus, WHO recommended vaccination for individuals at
higher risk of serious disease, and healthcare workers, as a priority. Similarly, antiviral
treatment is recommended for treatment of seriously ill patients, and those at higher
risk of progressing to serious disease, but in the context of local epidemiological
information. This latter point in particular allows for the fact that the likelihood of
influenza-like illness being due to pandemic H1N1 will vary with seasons.
Influenza vaccines are one of the most effective ways to protect people from
contracting illness during influenza epidemics and pandemics. This is especially
important for those persons at higher risk of severe or complicated illness, and in these
situations vaccination helps to prevent such severe illness and death. Similarly,
antivirals have been proved to reduce or prevent severe illness and prevent death,
especially in persons already at higher risk of developing severe influenza illness.
WHO's guidelines for use of vaccines and antivirals are consistent with the above
proven benefits.
6. How many cases of influenza, as a proportion of influenza-like illness, were
there in the last five years and related hospitalisations and deaths? (exact
numbers verified by laboratory tests). How was it calculated? If it is not
possible to quantify seasonal (ordinary) influenza, how is it possible to know
what is extraordinary (pandemic) influenza?
At a global level, some countries have adequate surveillance systems and data to
monitor influenza epidemics. Based on such data and systems, studies and models
have estimated the burden of influenza and have shown that the proportion of illnesses
and hospitalizations attributable to influenza is highly variable. For example, patterns
in the tropics differ from those in temperate zones -- and over time -- proportions are
usually higher in the winter than the summer in temperate climate zones.
As described in the responses to Questions 1 and 2, the differences between seasonal
and pandemic influenza relate to a combination of epidemiological, virological and

clinical features. In contrast to seasonal influenza epidemics, the H1N1 pandemic has
differed in several important respects. These include:
§ A higher incidence of severe illness and hospitalization in children and young
adults than is usual with seasonal influenza
§ The occurrence of epidemics in several regions of the world outside the
normal seasonal periods for influenza
§ A higher incidence than usual of viral pneumonia, which has been observed
in previous pandemics, and which is difficult to treat, than in seasonal
influenza
§ Lack of pre-existing immunity from either natural infection by current
seasonal influenza viruses or by vaccination
§ The almost complete displacement of the previous seasonal H1 virus, and a
significant displacement of the other seasonal A strain (H3N2), as was seen for
previous pandemics.
7. WHO states that 250,000 to 500,000 deaths from seasonal influenza occur
on average each year. What are WHO’s estimates of the annual number of
deaths attributable to non-influenza virus caused influenza-like illnesses
(ILI), and what is WHO doing to address this problem?
The influenza estimate was made in 2002 based on well-accepted studies done in
temperate industrialized countries and extrapolated to estimate the world-wide impact
of seasonal influenza. At a global level the proportion of pneumonia-related deaths due
to non-influenza viral infections is not known.
WHO has a broad based approach to the reduction of such deaths including support to
countries in developing critical health capacities, information and guidance in several
areas, advocacy, coordination of global surveillance, biannual updating of influenza
candidate vaccine strains and assistance with outbreaks.
8. Were WHO pandemic planning assumptions and guidance to states based
on the assumption that avian influenza H5N1 would cause the next pandemic?
The revisions of the guidelines were based on a broad assessment of new scientific
knowledge and public health experience as well as study of past pandemics (1918,
1957, 1968). Contemporary experience took into account H5N1 infections, and several
human influenza infections due to other animal viruses (H3, H9, H7). The revisions also
reflected work of modelling groups that helped delineate the range of outcomes that
might be expected.
9. Can you please provide the most recent estimates for H1N1 – persons
contracting the disease, numbers died, numbers inoculated, vaccines ordered
(and not used)? Can you also explain why the number of deaths from H1N1
has fallen far short of the self-described “relatively conservative estimate –
from 2 million to 7.4 million deaths” that WHO said would occur in a future
pandemic?
As of 7 May 2010, worldwide more than 214 countries and overseas territories or
communities have reported laboratory-confirmed cases of pandemic influenza H1N1
2009, and over 18,000 laboratory confirmed deaths. This number is, fortunately, well
below the figures quoted for previous pandemics and this may be attributable to two
factors:
§ Pandemic H1N1 has had a relatively low infection rate in the elderly. Since
the elderly are particularly vulnerable to influenza, and account for the
majority of deaths due to seasonal influenza epidemics, this low "attack rate"
in older age groups may have contributed to a lower than anticipated mortality
§ Even in groups that have experienced high rates of infection, the death rate
("case fatality rate") has been lower than observed in previous pandemics, an

observation which could not have been predicted at the start of the pandemic.
This is likely to be due to the properties of the virus itself, but advances in
medical care (such as intensive care, newer antivirals) will have made some
contribution to this.
Other considerations are also important when considering the mortality data currently
available:
§ The current numbers of deaths reported for the H1N1 pandemic reflect
deaths that were laboratory tested and individually confirmed. Estimates for
previous pandemics and seasonal influenza epidemics are determined by
retrospective statistical estimation of "excess deaths" during the period of an
epidemic or pandemic. This gives a better estimate of the actual impact of the
pandemic. A more accurate and complete assessment of mortality from this
pandemic, using statistical models, will take about one to two years after the
pandemic has ended and complete national mortality data are available.
§ Most of the deaths that have been recorded for this pandemic have occurred
in younger age groups. The impact of the pandemic in terms of "years of life
lost" is therefore higher than indicated by the absolute numbers.
WHO provided potential numbers of pandemic deaths to help national planners develop
preparedness plans. Effective planning is difficult if not impossible to conduct without
some range of figures.
10. Can you please provide a definition of "new influenza virus"?
See answer to question 2. In terms of the potential for virus to cause a pandemic of
influenza, the most important determinants of whether an influenza virus should be
considered a pandemic candidate is whether it is infectious for humans, where it can
spread sustainably among humans, and whether there is no or little pre-existing
immunity to this virus.
11. If classical aspects of pandemics, such as high attack rates and severity,
are not taken into consideration, what is the remaining public health rationale
for treating pandemics any differently than we treat seasonal influenza?
The future course of a pandemic cannot be predicted at its onset, or even through
much of its course. Pandemics are treated differently than seasonal influenza because
they have a potential to cause more severe disease and death among more people
than seasonal influenza. They also have the potential to cause significant social
disruption. Since manufacturing capacity and supplies of influenza vaccines and
antiviral drugs are geared to seasonal incidence and demand, they may not be
available during high levels of pandemic disease. As was seen with the current H1N1
pandemic, population groups not normally considered at risk for complications of
severe influenza disease may be at high risk, requiring changes to public health policy.
B.

WHO’S STANCE ON VACCINES

12. What concerns did WHO have about the vaccines and their suitability /
risks? Has the position changed? What view did WHO have on pharmaceutical
companies declining responsibility for the vaccines and seeking to transfer
this responsibility on to Governments ordering the vaccines?
Pandemic influenza vaccines underwent the same testing methods as seasonal
influenza vaccines. The increased timeliness was achieved not by any compromise in
quality assurance or testing rigor but due to a collaborative effort by countries and
officials to review and approve the vaccine in the most timely manner possible in a
time of great uncertainty and public health concern. This shows what can be achieved
through international collaboration in a public health emergency.
Outcomes of studies completed to date show that pandemic vaccines have a similar
safety record as seasonal influenza vaccines
WHO is not involved in country-level decisions regarding the purchase of vaccines.

13. Could the viral infection have been prevented with vaccines in stock? If
not, why not?
No. Studies on human immune responses have confirmed that an immune response to
the seasonal H1 will not protect against pandemic H1 virus and therefore the seasonal
influenza vaccines could not confer protection against the pandemic virus.
14. Has WHO done any head-to-head studies to compare behavioural
interventions such as hand washing versus vaccines?
WHO has not commissioned or conducted any such studies. Moreover, such
interventions are complementary rather than competitive options.
C.

RELATIONS WITH INDUSTRY, EXPERTS AND CONFLICT OF INTEREST

15. What steps are being taken by WHO to be more transparent and to avoid
conflicts of interest with pharmaceutical companies?
Whenever WHO utilizes outside expertise for a particular activity, the experts
concerned are required to complete a WHO Declaration of Interest form (DOI) in
advance of their participation in that activity (generally an expert meeting or other
work, aimed at providing expert advice to WHO).
Through the DOI, each expert is 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.
Conflict of interest means that the expert, or his/her partner, or the administrative unit
with which the expert has an employment relationship, has a financial or other interest
in a commercial entity 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.
The information submitted by the expert is assessed by the WHO Secretariat and may,
depending on the situation, result in a number of measures to curtail any real or
perceived conflicts. Such measures may range from total to partial exclusion from the
activity, and/or public disclosure of the interest (i.e. at the start of the meeting and in
the report of activity). As reports of expert meetings are generally published by WHO,
information on experts' disclosed interests are generally available to the public.
Regarding WHO staff, in addition to general rules which apply to all staff, certain
categories of staff must file declarations of interest each year to identify potential
conflicts of interest that could affect their objectivity and independence.
16. How does WHO define an inappropriate conflict of interest?
Information disclosed in the WHO DOI for experts is used to determine whether the
declared interests constitute an appreciable real, potential or apparent conflict of
interest. An appreciable real conflict of interest is defined as the expert having 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 is defined as an
interest that would not necessarily influence the expert but could result in the expert’s
objectivity being questioned by others. A potential conflict of interest is defined as an
interest which any reasonable person could be uncertain whether or not should be
reported.
17. Please provide more details on the “public-private partnerships for health”
system in relation to the pandemic influenza preparedness, and in particular
the development of “benefit sharing arrangements with influenza vaccine
manufacturers”?

WHO works with government, civil society and private sector partners to advance
public health, including for risk assessment and control as stipulated under the
International Health Regulations. Concerning benefits sharing arrangements for
influenza, this remains an area of negotiation by the Member States of WHO. The latest
framework containing a number of agreed sections is available publicly in the World
Health Assembly document WHA A62/5Add.1
(http://apps.who.int/gb/ebwha/pdf_files/A62/A62_5Add1-en.pdf). Additional
information on the intergovernmental process is available at
http://apps.who.int/gb/pip.
Financing and in-kind support have been secured both multilaterally and bilaterally
during recent years; These include options to stockpile H5N1 and H1N1 vaccines and
antiviral agents through donations from governments and industry, and agreements for
technology transfer. In addition support has been received for capacity building for
laboratory surveillance and pandemic response, as required under the International
Health Regulations (2005)
With the onset of pandemic A(H1N1), WHO worked closely with Member States and the
pharmaceutical industry to identify means to obtain required vaccines and antiviral
drugs. WHO reported to its Executive Board at its 126th session in January 2010 with
information on the pharmaceutical industry's donations of pandemic vaccine and
antiviral medicines, as well as funding to WHO to support its response activities.
18. Please provide more details on the selection methods of experts to WHO
advisory bodies and expert committees (including the “Review committee”);
The selection of experts to WHO expert committees (including the Review Committee)
is governed by the Regulations for Expert Advisory Panels and Committees (and the
International Health Regulations, in the case of the Review Committee). Experts to
WHO expert committees, including the Review Committee, are selected from WHO
expert advisory panels on the basis of the principles of equitable geographical
representation, gender balance, a balance of experts from developed and developing
countries, representation of different trends of thought, approaches and practical
experience in various parts of the world, and an appropriate interdisciplinary balance.
Selection of members of WHO expert advisory panels is based primarily on their
technical ability and experience. Efforts are also to be made to ensure that the panels
have the broadest possible international representation in terms of diversity of
knowledge, experience and approaches in the fields for which the panels are
established.
19. Please provide more details on the system in place to prevent or curb
conflicts of interest: is there a questionnaire? Are declarations of interest filed
and consultable, and if so by whom (member states)? If there are
consultations with the experts on these issues, are reports drafted afterwards
and are these available and consultable and if so by whom?
See the answer to question 15 above. The completed WHO DOIs are filed by the WHO
Secretariat. As noted above, the reports of WHO expert meetings generally contain
information on appreciable conflicts of interest which were declared by the participating
experts. Since such reports are generally published, the information is as such
available to the public.
20. Dr Keiji Fukuda told the Council of Europe on 26 January 2010: "Providing
independent advice to member states is a very important function of the WHO
that is taken seriously. WHO guards against the influence of any improper
interests". In that light, what evidence did WHO base itself on in
recommending the use and stockpiling of TAMIFLU (e.g. to reduce
complications of influenza4). Did WHO do an analysis of the drug independent
of that done by the manufacturer of the drug?
WHO published guidelines for the use of antivirals in August 2009, subsequently
revised and republished March 2010.

These guidelines were based on an independent review of the available evidence
conducted for WHO by independent consultants. The evidence review was then used by
an expert panel in the formulation of specific treatment recommendations.
In the published guidelines, WHO has ensured full transparency both in the process
followed, and in the basis for the recommendations. The documentation includes:
§ statement on the quality of clinical evidence that supports each
recommendation
§ details of the methods for evidence review, the published studies that were
considered, and the assessment grading
§ Full list of members of the expert panel, and disclosure of their relevant
interests
21. In their review of the 1976 “swine flu fiasco*”, Neustadt and Fineberg
write: “In a swine flu case when evidence is thin … it is not only the
assumptions but appraisal of their scientific quality that top decision-makers
need. Panels tend toward ‘group think’ and over-selling, tendencies nurtured
by long-standing interchanges and intimacy, as in the influenza fraternity.
Other competent scientists, who do not share their group identity or vested
interests, should be able to appraise the scientific logic applied to available
evidence”.What steps did and does WHO take to include experts with diverse
or contrary views into its advisory and policy guidance preparation process
and to avoid what is being referred to as ‘group think’?
Please see response to question 18.
22. What systems are in place to analyse WHO recommendations and whether
they were appropriate and well founded?
23. What lessons have been learnt from the H1N1 pandemic?
An in-depth review of the global response to the influenza pandemic began in April. An
external Review Committee, convened under the International Health Regulations
(IHR), will examine how the world and WHO responded to the pandemic H1N1.
The overarching goal is to identify lessons learned and ways to improve how the world
can work together to protect global health during a public health emergency.
This rigorous, external review of the global response to pandemic H1N1 is an
unprecedented process that will influence public health decision-making during the
next pandemic, and in other public health emergencies of international concern.
1

Reference to Committee: Doc. 12110, Reference 3639 of 29 January 2010.

2

Draft resolution adopted by the Committee on 4 June 2010.

3

Draft recommendation adopted by the Committee on 4 June 2010.

4

The United Nations and the Private Sector – A framework for Collaboration. Global
Compact Office, United Nations, September 2008.
5

Philip Alcabes, Professor of Urban Public Heath at Hunter College’s School of Health
Sciences and in the Public Health program at the Doctoral School, City University of
New York: “Dread - How Fear and Fantasy have Fuelled Epidemics from the Black
Death to the Avian Flu”. Public Affairs 2009.
6

See also the written replies provided by WHO on 17 May 2010 as appended to this
report.
7

WHO: Transcript of the virtual press conference held on 14 January 2010 with Dr Keiji
Fukuda, Special Adviser to the Director-General on Pandemic Influenza, WHO.

8

According to WHO: Pandemic influenza preparedness and response: a WHO guidance
document, May 2009, pandemic phases 5 and 6 are jointly worded as follows: Phase 5:
The same identified virus has caused sustained community level outbreaks in two or
more countries in one WHO region. Phase 6: In addition to the criteria defined in Phase
5, the same virus has caused sustained community level outbreaks in at least one
other country in another WHO region.
9

WHO contests that the severity of the disease was ever a pre-condition for pandemic
influenza phase 6, see Appendix.
10

WHO: Pandemic (H1N1) 2009 – Weekly update 90, 5 March 2010.

11

WHO: Progress in public health during the previous decade and major challenges
ahead. Dr Margaret Chan, Director-General, Report to the Executive Board at its 126th
session, Geneva, Switzerland, 18 January 2010.
12

WHO: Pandemic (H1N1) 2009 vaccine deployment update – 14 May 2010

13

European Commission / Directorate of Health and Consumers: Pandemic (H1N1)
2009 – Factsheet, March 2010.
14

WHO: Pandemic (H1N1) 2009 vaccine deployment update – 31 March 2010

15
See for example The Parliamentary Office of Science and Technology (POST) of the
United Kingdom, Postnote 331 in May 2009, London, saying: “The Department of
Health (DH) has ‘sleeping contracts’ with two manufacturers (Baxter and GSK) which
reserve a certain number of doses of any vaccine developed against a pandemic flu
strain.”
16

See interviews with epidemiologist Tom Jefferson of the Cochrane Collaboration: “A
whole industry is waiting for a pandemic”. Der Spiegel (Germany), 21 July 2009, and
with Prof. Marc Gentilini : Pour Marc Gentilini, on assiste à une "pandémie de
l'indécence", Le Monde, 06.08.09.
17

Articles 1 and 2 of the WHO Constitution as adopted by the International Health
Conference held in New York on 22 July 1946 by the representatives of 61 States and
entered into force on 7 April 1948 (and as amended in 1977, 1984, 1994, and 2005
respectively).
18

See interview with epidemiologist Tom Jefferson of the Cochrane Collaboration: “A
whole industry is waiting for a pandemic”. Der Spiegel (Germany), 21 July 2009.
19

The Cochrane Collaboration (Working together to provide the best evidence) for
health care is a not-for-profit international network of researchers, practitioners and
consumers who prepare and update systematic reviews of the effects of healthcare
interventions (drugs, vaccines, devices, procedures, service delivery, training, quality
control mechanisms etc). Cochrane reviews seek to bring together all of the research
on a topic, to minimise bias and to provide independent, reliable information to help
decision makers. There are now more than 4 000 full Cochrane reviews. The
Collaboration has a structure including thirteen Cochrane Centres and just over 50
Cochrane Review Groups spread around the world – www.cochrane.org
20

"WHO faces questions over swine flu policy", BBC News, Geneva, Thursday 20 May
2010.
21

Quoting from the exchange of views with Dr Keiji Fukuda, Special Advisor on
Pandemic Influenza to the Director-General of WHO, at the public hearing organised by
the Social, Health and Family Affairs Committee in Strasbourg on 26 January 2010.
22

Elisabeth Fisher: “Is the precautionary principle justiciable?” Journal of
Environmental Law, Vol. 13, N 3, Oxford University Press.
23

Peter Doshi: Calibrate response to emerging infections, BMJ 2009, 339:b3471

24

WHO: Pandemic influenza preparedness and response: a WHO guidance document,
May 2009.
25

All quotations compiled by Dr Tom Jefferson, Cochrane Collaboration, and presented
at the public hearing of the Social, Health and Family Affairs Committee of the
Parliamentary Assembly in Paris on 29 March 2010.
26
Kent Buse & Amalia Waxman: Public-private health partnerships: a strategy for
WHO, Bulletin of the World Health Organization, 2001, 79 (8)
27

Dr Tom Jefferson in his statement made at the public hearing of 29 March 2010

28

Fiona Godlee at the exchange of views with the Social, Health and Family Affairs
Committee in Paris on 4 June 2010 quoting from Deborah Cohen, Philip Carter: WHO
and the pandemic flu “conspiracies”, BMJ website 4 June 2010.
29

Stéphane Horel: “Les Médicamenteurs – Labos, Médecins, Pouvoirs publics : enquête
sur des liaisons dangereuses“, Editions du moment, Février 2010.
30

Request addressed by several parliamentarians to WHO representative Dr Keiji
Fukuda at the public hearing organised by the Assembly’s Social, Health and Family
Affairs Committee on 26 January 2010.
31

WHO: Pandemic (H1N1) 2009 briefing note 19, 3 December 2009, Geneva.

32

WHO: Transcript of the virtual press conference held on 14 January 2010 with Dr
Keiji Fukuda, Special Adviser to the Director-General on Pandemic Influenza, WHO.
33

Neustadt and Fineberg in their review of the 1976 “swine flu fiasco”: The Swine Flu
Affair, 1978:89.
34

Deborah Cohen, Philip Carter: WHO and the pandemic flu “conspiracies”, BMJ website
4 June 2010.
35

See statement by WHO Director-General, Dr Margarat Chan, on 29 April 2010

36

Dr Keiji Fukuda, Special Advisor to WHO Director-General on Pandemic Influenza, at
the public hearing organised by the Parliamentary Assembly’s Social, Health and Family
Affairs Committee on 26 January 2010.
37

Deborah Cohen, Philip Carter: WHO and the pandemic flu “conspiracies”, BMJ website
4 June 2010.
38

Names regularly referred to by the specialised press include: Novartis,
GlaxoSmithKline, Sanofi-Aventis, Astrazeneca, Sinovac, Baxter International, Inovio
Biomedical, Novavax, CSL, Solvay, Hualan Biological, Green Cross.
39

European Vaccine Manufacturers (EVM) statement on Council of Europe debate on
‘Faked Pandemics – a threat for health’, edited on 14 January 2010, Brussels.
Statement presented by Dr Luc Hessel, EVM, at the public hearing on 26 January 2010.
40

EMEA: Pandemic influenza A(H1N1)v vaccines authorised via the core dossier
procedure. Explanatory note on scientific considerations regarding the licensing of
pandemic A(H1N1)v vaccines. London. 24 September 2009.
41

The adjuvants are so-called inert products which are added to a vaccine in order to
stimulate the immune reaction by reinforcing the production of antibodies, such as
Squalene or Thiomersal (Sources: EMEA and Prof. Daniel Floret, Technical Director of
the High Council of Public Health in France, September 2009)
42

Stéphane Horel : “Les Médicamenteurs – Labos, Médecins, Pouvoirs publics : enquête
sur des liaisons dangereuses, Editions du moment“, Février 2010.
43

As described by Dr Wolfgang Wodarg, epidemiologist at the public hearing of 26
January 2010.

44

European Medicines Agency (EMEA): Explanatory note on scientific considerations
regarding the licensing of pandemic influenza A(H1N1)v vaccines, London 24
September 2009.
45

Idem as footnote 12.

46

Agence France Presse (AFP) on 9 February 2010.

47

Fiona Godlee, Mike Clarke: “Why don’t we have all the evidence on oseltamivir?” BMJ
2009, 339: b5351.
48

Various press articles, such as Reuters on 25 February 2010 and Ouest France on 25
March 2010.
49
Stéphane Horel : Les Médicamenteurs – Labos, Médecins, Pouvoirs publics : enquête
sur des liaisons dangereuses, Editions du moment, Février 2010.
50

Office parlementaire d’évaluation des choix scientifiques et technologiques (OPECST),
Assemblée nationale, Paris : Audition publique du 1 décembre 2009 – « Face à la
grippe A(H1N1) et la mutation des virus, que peuvent faire chercheurs et pouvoirs
publics ? »
51

As reported by Associated Press on May 19, 2009, and quoted by Dr Wolfgang
Wodarg, German epidemiologist at the public hearing of 26 January 2010.
52

European Centre for Disease Control and Prevention (ECDC): ECDC Daily Update on
the 2009 influenza A(H1N1) pandemic, 19 January 2010.
53

"Pandemic" A Dictionary of Public Health. Ed. John M. Last, Oxford University Press,
2007. Oxford Reference Online. Oxford University Press. Accessed on 25 March 2010 at
www.oxfordreference.com