WHO's Final Report on the functioning of the International Health Regulations (IHR) in relation to the 2009 A(H1N1) pandemic - the Fineberg report
In January 2010 the World Health Organization (WHO’s) Executive Board endorsed a proposal from the WHO Director-General to convene a Committee with an independent chair to review the working of the 2005 International Health Regulations (IHR), and the experience gained in the global response to the 2009 influenza pandemic.
Report by the Director-General of the World Health Organization (WHO), 64th World Health Assembly (WHA) - Geneva, Switzerland, 5th May 2011
In January 2010 the World Health Organization (WHO’s) Executive Board endorsed a proposal from the WHO Director-General to convene a Committee with an independent chair to review the working of the 2005 International Health Regulations (IHR), and the experience gained in the global response to the 2009 influenza pandemic. Effectively this was to review the global handling of the pandemic and what lessons should be learnt. The review of the operation of the new regulations was expected and required in the Regulations themselves. It followed the Regulations being radically different from their predecessors.(1) The review of the handling of the pandemic was a ‘lessons learnt’ exercise to help modify future responses and so strengthen preparedness for future pandemics. However it also followed criticism of WHO and the global response by bodies like the Parliamentary Assembly of the Council of Europe and specific allegations including that WHO had succumbed to pressures from commercial pharmaceutical companies and that the risk of the pandemic had been over-stated both by WHO and member states.(2) The members of the Committee were persons nominated by Member States and were a mix of experts in public health, emergency response and influenza. Following a protracted process, close examination of WHO itself and much personal and corporate testimony, including from ECDC (3) the review was published and debated by the 64th World Health Assembly in May 2011 where it was adopted.(4) The review is referred to as the Fineberg report after its chairman Dr Harvey Fineberg head of the US Institute of Medicine who co-authored a previous report on an influenza incident.(5) .
The review committee was given three key objectives:• Assess the functioning of the International Health Regulations (2005);• Assess the ongoing global response to the pandemic H1N1 (including the role ofWHO); and• Identify lessons learned important for strengthening preparedness and response for future pandemics and public-health emergencies.
The Committee conducted most of its work through plenary meetings in Geneva that were open to Member States, the media and the public. The Committee and its working groups also met for deliberative sessions in Geneva, open only to members of the Committee and its immediate support staff. While operating independently, the Review Committee frequently sought information from WHO’s Secretariat, asking for clarification of issues that arose during the information-gathering and report-writing periods. Additionally, the Committee was informed by a remote survey of country general and pandemic preparedness plus a series of briefing notes developed by the WHO Secretariat which provided background on specific issues. These included the IHR, pandemic preparedness, pandemic phases, pandemic severity, pandemic vaccines, antiviral drugs, virological monitoring, disease monitoring, laboratory response, public health measures. In parallel, and of considerable relevance, was an Open-ended Working Group OEWG) of member states on pandemic influenza preparedness: sharing of influenza viruses and access to vaccines and other benefits.(6) In summary, the Committee sought to document WHO’s and member states roles and management in response to the pandemic and to evaluate the effectiveness of the IHR in their first few years of use. This required a thorough investigation of events and decisions in the course of the pandemic and an examination of criticisms of the WHO as well as an assessment of its achievements.
The Committee report offers 3 overarching summary conclusions and 15 recommendations for WHO and Member States. These are as follows (many of the recommendations have more detailed sub-recommendations which deserve examination but are not listed here):
Summary conclusion 1The adoption of IHR 2005 has helped make the world better prepared to cope with public-health emergencies. However the core national and local capacities called for in the IHR are not yet fully operational in member states and are not at present on a path to timely implementation worldwide. Good as the IHR are they lack consequences and sanctions if a member state does not follow them. In some countries the IHR focal point does not even have the authority to convey information to WHO.
- Recommendation 1
Member states should accelerate implementation of core capacities required by the IHR.
- Recommendation 2
WHO should enhance its Event Information Website.
- Recommendation 3
WHO and member states should make decisions on international travel and trade in relation to potential public health emergencies more evidence-based.
- Recommendation 4
Member states should ensure that all National IHR Focal Points have the necessary authority and resources to operate effectively.
Summary conclusion 2WHO performed well in many ways during the pandemic, confronted systemic difficulties but also demonstrated some shortcomings. Because of prior activity by WHO, member states and others three quarters of countries world-wide had pandemic plans by 2009. Specifically the Review Committee found no evidence of malfeasance (wrong-doing) in relation to commercial pressures or influence as alleged by some.(2) Equally the Committee concluded that WHO did not exaggerate the severity of the pandemic but was critical of a number of its communication activities and WHO’s handling of its Emergency Committee. It was also critical of member states and WHO spending time counting cases rather that producing rates and analyses. Consequently there were a number of improvements recommended for WHO, the global pandemic response and member states.
- Recommendation 5
WHO should strengthen its internal capacity for making sustained responses to emergencies.
- Recommendation 6
The mechanism for WHO appointing an Emergency Committee under the IHR should be improved and be made more transparent.
- Recommendation 7
WHO should revise its pandemic preparedness guidance in the light of the 2009 experience (while at the same time it must not be assumed that the next pandemic will necessarily resemble 2009 or any other pandemic).(7)
- Recommendation 8
WHO should with member states develop measures to assess severity of pandemics but also apply these for seasonal influenza .
- Recommendation 9
The management of its guidance documents should be streamlined by WHO.
- Recommendation 10
WHO should develop and implement a strategic, organization-wide communications policy.
- Recommendation 11
Improved advance agreements for vaccine distribution and delivery should be developed.
Summary conclusion 3The world is ill-prepared to respond to a severe influenza pandemic or to any similarly global, sustained and threatening public-health emergency. Beyond implementation of core public-health capacities called for in the IHR, global preparedness can be advanced through research, reliance on a multisectoral approach, strengthened health-care delivery systems, economic development in low and middle-income countries and improved health status of the population.
- Recommendation 12
A more extensive global, public-health reserve workforce should be established by member states in concert with WHO.
- Recommendation 13
There should be a contingency fund for public-health emergencies held outside of WHO but available to WHO in an emergency. .
- Recommendation 14
Agreement should be reached on sharing of influenza viruses and access to vaccines and other benefits with the latter built around the GAP programme of WHO.
- Recommendation 15
Member states and WHO should continue to pursue comprehensive influenza research and evaluation programmes.
ECDC’s listing of Pandemic Evaluations
ECDC Comment (10/06/2011)
As can be seen though the Review Committee cleared WHO of wrong-doing in relationship to pharmaceutical companies, or exaggerating the severity of the 2009 pandemic WHO certainly did not escape criticism. This was especially in the lack of openness over the working of the Emergency Committee and communications in general. It also noted the difficulties that WHO faced in responding to a sustained crisis. At the same time The Review Committee acknowledged that both WHO and all member states faced a most difficult challenge in preparing for and responding to as uncertain a threat as a pandemic. Generally it was noted that plans were set for a severe and lacked flexibility, points noted by ECDC and many European authorities in their reviews.(7) One important development, agreement on virus sharing and benefit sharing has already been agreed and this was endorsed at the 64th World Health Assembly in May.(6) EU authorities are showing leadership since the European Commission has taken the initiative following EU Council encouragement to develop joint procurement procedures with interested member states. At the same time ECDC, working with the European Commission and WHO Regional Office for Europe is leading the revision of the European Pandemic Preparedness Indicators for Member States in the light of the pandemic 2009 experience.(8)
References:
- WHO International Health Regulations (2005).
- Flynn P. Social, Health and Family Affairs Committee. Parliamentary Assembly of the Council of Europe. The handling of the H1N1 pandemic: more transparency needed. 2010.
- Sprenger M. ECDC Evidence to the Fineberg Committee Add date and link from our evaluations listing.
- Implementation of the International Health Regulations (2005) - Report of the Review Committee on the Functioning of the International Health Regulations (2005) in relation to Pandemic (H1N1) 2009 Report by the Director-General of the World Health Organization (WHO), 64th World Health Assembly (WHA) - Geneva, Switzerland, 5th May 2011
- Neustadt RE, Fineberg HV. The swine flu affair: decision making on a slippery disease. Washington: US Department of Health, Education and Welfare 1978.
- Nicoll A, Sprenger M. Learning lessons from the 2009 pandemic: putting infections in their proper place. Eur J Epidemiol 2011; 10.1007/s10654-011-9575-4
- ECDC – European Commission – WHO Regional Office for Europe. European Pandemic Preparedness Indicators
