Article

The Elusive Definition of Pandemic Influenza

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Abstract

There has been considerable controversy over the past year, particularly in Europe, over whether the World Health Organization (WHO) changed its definition of pandemic influenza in 2009, after novel H1N1 influenza was identified. Some have argued that not only was the definition changed, but that it was done to pave the way for declaring a pandemic. Others claim that the definition was never changed and that this allegation is completely unfounded. Such polarized views have hampered our ability to draw important conclusions. This impasse, combined with concerns over potential conflicts of interest and doubts about the proportionality of the response to the H1N1 influenza outbreak, has undermined the public trust in health officials and our collective capacity to effectively respond to future disease threats. WHO did not change its definition of pandemic influenza for the simple reason that it has never formally defined pandemic influenza. While WHO has put forth many descriptions of pandemic influenza, it has never established a formal definition and the criteria for declaring a pandemic caused by the H1N1 virus derived from "pandemic phase" definitions, not from a definition of "pandemic influenza". The fact that despite ten years of pandemic preparedness activities no formal definition of pandemic influenza has been formulated reveals important underlying assumptions about the nature of this infectious disease. In particular, the limitations of "virus-centric" approaches merit further attention and should inform ongoing efforts to "learn lessons" that will guide the response to future outbreaks of novel infectious diseases.

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... Theoretically, the word pandemic was used around 1666 [12] and later on endorsed by WHO in 1999 [13]. By that time it was referred to as "a Pandemick or Endemick or rather a Vernacular Disease (a disease always reigning in a country" [12]. ...
... In other words, a pandemic is global epidemic [16]. Various scholars consent that the following diseases met the definition or guidelines of pandemic: acute hemorrhagic conjunctivitis (AHC), AIDS, cholera, dengue, influenza, plague, severe acute respiratory syndrome (SARS), Corona virus, scabies, Ebola, HIV/AIDS, West Nile disease, and obesity [7,10,12,13]. [13,[17][18][19]. History and science suggest that pandemic "will strike again" [20][21][22]. ...
... Various scholars consent that the following diseases met the definition or guidelines of pandemic: acute hemorrhagic conjunctivitis (AHC), AIDS, cholera, dengue, influenza, plague, severe acute respiratory syndrome (SARS), Corona virus, scabies, Ebola, HIV/AIDS, West Nile disease, and obesity [7,10,12,13]. [13,[17][18][19]. History and science suggest that pandemic "will strike again" [20][21][22]. ...
... A pandemic is a disease that simultaneously breaks out in multiple geographical locations worldwide, caused by a new and highly pathogenic microbe (or a variant thereof) to which humans have no prior immunological resistance [4]. A pandemic disease can easily cross international borders and spread within communities, constituting a public health emergency of international concern (PHEIC). ...
... A pandemic disease can easily cross international borders and spread within communities, constituting a public health emergency of international concern (PHEIC). Therefore, a swift and coordinated effort that focuses the attention and resources of governments and the public health community is always necessary to respond to and ultimately end a pandemic [4]. In the past 20 years, the World Health Organisation (WHO) has declared 6 diseases as constituting PHEICs (Table 1) [4−7]. ...
... "Health communication" pertained to the dissemination of health messages aimed at influencing behavior change within the realm of health [33]. A "pandemic" was characterized as an emerging infectious disease with rapid international spread among humans, where no prior immunity existed [4]. Out of the 6 diseases declared as PHEICs in the past 20 years, poliomyelitis and monkeypox were excluded. ...
Article
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Public health agencies (PHAs) have increasingly incorporated social media into their communication mix during successive pandemics in the 21st century. However, the quality, timing, and accuracy of their health messages have varied significantly, resulting in mixed outcomes for communication, audience engagement, and pandemic management. This study aimed to identify factors influencing the effectiveness of pandemic-related health messages shared by PHAs on social media and to report their impact on public engagement as documented in the literature. A scoping literature review was conducted following a predefined protocol. An electronic search of 7 relevant databases and 5 grey literature repositories yielded 9,714 papers published between January 2003 and November 2022. Seventy-three papers were deemed eligible and selected for review. The results underscored the insufficiency of social media guidance policies for PHAs. Six themes were identified: message source, message topic, message style, message timing, content credibility and reliability, and message recipient profile. These themes encompassed 20 variables that could inform PHAs’ social media public health communication during pandemics. Additionally, the findings revealed potential interconnectedness among the variables, and this study concluded by proposing a conceptual model that expands upon existing theoretical foundations for developing and evaluating pandemic-related health messaging.
... The H1N1 pandemic, which circulated from early 2009 to late 2010, spread in 198 countries and regions around the world and caused at least 575,000 deaths, causing serious damage to the global socioeconomic environment [15]. Although the 2009 pandemic was relatively mild [16], it shared a similar policy and technical background to COVID-19. On the one hand, it was the first real-world campaign since the entry into force of the revised International Health Regulation (2005), which provided a legal framework and a specialized mechanism for collective global action [17]. ...
... According to the time of declaration and cessation of the global health emergency by WHO, H1N1 lasted 16 months, while COVID-19 lasted 39 months [1]. Thus, just as most assessors claimed that the 2009 pandemic was mild [16]. A comparison of empirical case studies from the two periods [71,72] showed that both adopted consistent community mitigation measures under IHR guidance. ...
Article
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The COVID-19 pandemic has brought enormous casualties and huge losses to cities around the world, causing urban planning to reflect on its serious inadequacy in public health crisis management. Looking back at the pandemics of modern history, urban planning has been dedicated to enhancing disease prevention capacity as well as improving the wellness of human beings. By systematically comparing the urban planning response between COVID-19 (2019) and its predecessor H1N1 (2009) in the literature, this paper seeks to explore how urban planning theories evolved through the pandemics and whether COVID-19 has led to possible new implications and directions for urban planning in the future. A total of 3129 related results with overlapping themes of “city”, “pandemic”, and “planning” in the database were narrowed down to 30 articles published between 2009 and 2019 on the topic of H1N1 and 99 articles published between 2020 and 2022 on the topic of COVID-19 after careful extraction and integration. Through bibliographic and detailed analysis, twelve urban theories used to fight against pandemics were identified. In addition, three main changes between urban planning responses to the H1N1 and COVID-19 pandemics were summarized: from focusing on stages of “in-pandemic” and “pre-pandemic” to focusing on stages of “post-pandemic”, from global and national to local, and from the absence of an urban-built environment to a return to ‘healthiness’ in urban planning and design. Such comparisons are useful for examining the current situation and providing suggestions for a possible upcoming outbreak.
... WHO pandemic influenza phases. Adapted from Doshi P.[20]. ...
... In the following months, changing the definition of a pandemic was discussed many times, but WHO staff insisted that there was no change in the definition of a pandemic [42]. Actually, it was true since WHO has never formally defined pandemic influenza either in the WHO documents or on the WHO websites [48]. However, in mid-summer 2011, the description of a pandemic on the WHO website reverted to its original definition with enormous numbers of deaths and illness [7]. ...
Article
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The article considers results of the study evaluating historical and epidemiological events that preceded and accompanied adjustment of the pandemic description on the WHO website in 2009 and 2011. The analysis covered publications related to epidemics and pandemics issues, the WHO documents, the WHO website. The descriptions of pandemic mostly focused on “enormous numbers of cases and deaths”. Since May 2009, new description of pandemic was published, focusing on disease prevalence. In 2011 it reverted to initial one with no comments. From perspective of the WHO document of 2009, declaration of swine flu pandemic in June 2009 seemed justified. However, considering previous pandemic history, common sense and consequences of declaring pandemic of disease with low both number of cases and mortality, it was premature move. Since primary factor hindering development of pandemic is effectiveness of infectious disease treatment, to minimize likelihood of new pandemic it is necessary to improve special medical education quality and to study and to adapt to modern conditions all effective medications and methods used in the past.
... 52 Actually, it was true since WHO has never formally defined pandemic influenza either in the WHO documents or on the WHO websites. 76 However, in mid-summer 2011, the description of a pandemic on the WHO website reverted to its original definition with enormous numbers of deaths and illness. 63 ...
Preprint
Full-text available
Teppone, Mikhail, Definition of a Pandemic: The Causes And Consequences Of Its Adjustment In 2009 And 2011 (May 30, 2024). Available at SSRN: https://ssrn.com/abstract=4848086 or http://dx.doi.org/10.2139/ssrn.4848086 Abstract: The study was carried out to evaluate historical and epidemiological events that preceded and accompanied the adjustment of the description of a pandemic on the WHO website in 2009 and 2011. Since the cause of the change in the description of a pandemic on the WHO website is not clear, analyses of the literature related to the epidemics and pandemics, WHO documents, WHO website, and articles published in journals and the Internet have been done. Until early May 2009, the description of the pandemic focused on "enormous numbers of cases and deaths." On May 6, 2009, a new description of the pandemic was published, focusing on the prevalence of the disease; in 2011 it reverted to the initial one without any comments. From the perspective of the WHO document issued in 2009, the declaration of a swine flu pandemic in June 2009 seemed justified. However, considering the previous pandemic history, common sense, and the consequences of declaring a pandemic for a disease not accompanied by a high number of cases and high mortality, it was a premature move. Since the primary factor hindering the development of a pandemic is the effectiveness of treating infectious disease, to minimize the likelihood of a new pandemic, it is necessary to improve the quality of special medical education and to study and adapt to modern conditions all effective drugs and methods used in the past.
... 52 Actually, it was true since WHO has never formally defined pandemic influenza either in the WHO documents or on the WHO websites. 76 However, in mid-summer 2011, the description of a pandemic on the WHO website reverted to its original definition with enormous numbers of deaths and illness. 63 ...
... On 5 May 2023, the Director-General of the WHO declared that COVID-19 was an established and ongoing health issue that no longer constituted a public health emergency of international concern (PHEIC) [3]. On the other hand, there is no rigorous quantitative definition of pandemics, let alone their endings [4][5][6], and the statement during the fifteenth meeting of the IHR (2005) Emergency Committee on the COVID-19 pandemic held on 4 May 2023 indicated that "it is time to transition to long-term management of the COVID-19 pandemic" [3]. ...
Article
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During the COVID-19 pandemic, while some countries succeeded in reducing their rate of death after SARS-CoV-2 infection via vaccination by the end of 2021, some of them also faced hospital capacity strain, leading to social anxiety about delays in the diagnosis and treatment of patients with other diseases. This essay presents an allegory to explain the situation during the COVID-19 pandemic. Through an allegory and Le Morte d’Arthur (Arthur’s Death), this essay indicates that “the scabbard of Excalibur” that we are looking for is an efficient and effective healthcare system that can diagnose patients who might become severely ill due to COVID-19 and to treat them without hospital capacity strain. In Le Morte d’Arthur, the scabbard of Excalibur was lost, and we have not been able to find any alternatives to end the COVID-19 pandemic. We can choose a future in which “the scabbard of Excalibur” exists, providing a different ending for the next pandemic.
... While there is no new vaccine combined for both influenza and COVID, there are separate vaccines for influenza and COVID. A famous influenza pandemic, very well acknowledged, from 1918, is known as the Spanish flu-18 [4]. It has an estimated projection of 40-50 million deaths. ...
Article
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Background Influenza and corona viruses generate vaccine preventable diseases and have pandemic potential, frequently dramatic. A co-infection with these viruses, may be a new worldwide threat, researchers name it flurona. The aim of our study is to assess flu and COVID-19 Romanian vaccination for 2022–2023 season and the factor associated with higher odds to receive flu and COVID-19 vaccine. Methods An analytical cross-sectional observational survey was conducted in the general population; a self-administered questionnaire was used. Results 1056 responders were analyzed, mean age 32.08 ±13.36 years (limits:18–76), majority, 880 (83.33%), from urban areas, 608 (57.58%), high school graduated, 400 (37.88%) parents. More than half of the responders were healthcare workers, 582 (55.11%), also considered study population. In the study group, 796 (73.37%) responders consider flurona vaccination useful; and 872 (82.57%) responders consider that no sanctions are needed for not flurona vaccinating. In the 2022–2023 season, 162 (15.34%) responders vaccinated against the flu and 300 (28.41%) against COVID-19. The factor associated with higher odds to receive flu and COVID-19 vaccine was the habit of flu vaccination: for flu (OR = 58.43; 95% CI: (34.95–97.67)) and for COVID-19 (OR = 1.67; 95% CI: (1.21–2.31)). Other factors such as having university degree (OR = 1.46; 95% CI: (1.08–1.98)) and being a healthcare worker, (OR = 1.41; 95% CI: (1.07–1.87)) were influencing factors only for adult COVID-19 vaccination in the 2022–2023 season. In the parents’ group, in 2022–2023 season, only 48 (12%) vaccinated their children against the flu and 68 (17%) against COVID-19, mostly parents that vaccinated themselves, p<0.001. In the 2022–2023 season, there were only 82 (7.65%) responders vaccinated against both diseases. Logistic regression analysis showed that no factor analyzed influenced the flurona vaccinated parent’s decision to vaccinate their children for flu and for COVID-19. Conclusions In the season 2022–2023, in Romania, the vaccination against flu and COVOD-19 is low, in adults and children as well. More efforts must be done to increase flurona vaccination, public health educational programs are strongly needed. Children, that are at greater risk when co-infecting with these viruses, must be vaccinated, school vaccination programs should be considered.
... Pandemics pose additional challenges on team functioning, including unexpected practice changes, delays in medical procedures, cancellations of treatments, and workforce shortages due to sickness [4]. Pandemics are characterized by community-level outbreaks in at least two countries within a World Health Organization (WHO) region and at least one other country in a different WHO region [5]. In the last two decades, pandemics have mainly involved respiratory viruses, including SARS (severe acute respiratory syndrome) in 2002-2003, H1N1 influenza (swine flu) in 2009-2010, the Ebola outbreak in West Africa in 2014-2016, the Zika Virus outbreak in 2015-2016, and the COVID-19 pandemic (2019-present), considered to be one of the most significant global health crises in recent history, caused by the novel coronavirus SARS-CoV-2. ...
Article
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Amid pandemics, health care teams face unprecedented challenges, requiring significant efforts to sustain optimal functioning and navigate rapid practice changes. It is therefore crucial to identify factors affecting team functioning in these contexts. The present narrative review more specifically summarizes the literature on key elements of cancer teams’ functioning during COVID-19. The search strategy involved four main databases (i.e., Medline OVID, EMBASE, PsycINFO, and CINAHL), as well as Google Scholar, from January 2000 to September 2022. Twenty-three publications were found to be relevant. Each was read thoroughly, and its content summarized. Across publications, three key themes emerged: (1) swiftly adopting virtual technology for communication and interprofessional collaboration, (2) promoting team resilience, and (3) encouraging self-care and optimizing team support. Our findings underscore key team functioning elements to address in future pandemics. More research is needed to document the perspectives of broader-based team members (such as patients and lay carers) to inform more comprehensive evidence-based team functioning guidelines.
... The WHO's definition of a pandemic requires that a novel respiratory virus, to which humans have little or no immunity, spreads aggressively in multiple regions of the world. There has been much debate about the motives of the WHO to remove a reference to a virus's morbidity and mortality ("enormous numbers of deaths and illness") from its web site just before the declaration of the 2009 swine flu as a pandemic (Doshi 2011). ...
Preprint
p>The novel coronavirus SARS-CoV-2 took a firm grip on human life in the year 2020. The global spread of the virus and the impacts of the associated disease COVID-19 are being tracked by numerous institutions, experts, and lay people. Thematic maps are widely used to visualize the many available metrics, including case counts, hospitalization rates, and fatalities. Despite coordination efforts at different jurisdictional levels (including global), data collection is partially inconsistent, delayed, or unfocused, and maps may exacerbate the issues of the underlying data. Numerous published maps also conflict with established cartographic guidelines and include design choices that exaggerate the spread of the coronavirus and the threat of COVID-19. This article highlights some of these issues and illustrates alternative representations that keep the pandemic in proportion. The distinction between using maps for data exploration and answering specific questions is examined, and the challenges to mapping the pandemic are related to standards of professional ethics in the GIS field.</p
... 51 Actually, it was true since WHO has never formally defined pandemic influenza either in the WHO documents or on the WHO websites. 61 However, in mid-summer 2011, the description of a pandemic on the WHO website reverted to its original definition with enormous numbers of deaths and illness. 53 ...
Preprint
Full-text available
Background: An analysis of the pages of the WHO website on the influenza pandemic revealed changes in the use of the term "pandemic" that occurred in 2009 and 2011. Materials and methods: Since the cause of the change in the description of a pandemic on the WHO website in 2009 and 2011 is not clear, analyses of the literature related to the epidemics and pandemics, WHO documents, WHO website, and articles published in journals and the Internet have been done.Results: Until early May 2009, the description of the pandemic focused on "enormous numbers of cases and deaths." On May 6, 2009, a new description of the pandemic was published, focusing on the prevalence of the disease, but in 2011 it reverted to the initial one without any comments. From the perspective of the WHO document issued in 2009, the declaration of a swine flu pandemic in June 2009 seemed justified. However, considering the previous pandemic history, common sense, and the consequences of declaring a pandemic for a disease not accompanied by a high number of cases and high mortality, it was a premature move.Conclusion: Since the primary factor hindering the development of a pandemic is the effectiveness of treating infectious diseases, but not a definition of a pandemic, to minimize the likelihood of a new pandemic, it is necessary to improve the quality of special medical education and to study and adapt to modern conditions all effective drugs and methods used in the past.
... [34] Actually, it was true since WHO has never formally defined pandemic influenza either in the WHO documents or on the WHO websites. [19] However, in mid-summer 2011, the description of a pandemic on the WHO website reverted to its original definition with enormous numbers of deaths and illness. ...
Preprint
Full-text available
Background: An analysis of the pages of the WHO website on the influenza pandemic revealed changes in the use of the term "pandemic" that occurred in 2009 and 2011. Materials and methods: Since the cause of the change in the description of a pandemic on the WHO website in 2009 and 2011 is not clear, analyses of the literature related to the epidemics and pandemics, WHO documents, WHO website, and articles published in journals and the Internet have been done.Results: Until early May 2009, the description of the pandemic focused on "enormous numbers of cases and deaths." On May 6, 2009, a new description of the pandemic was published, focusing on the prevalence of the disease, but in 2011 it reverted to the initial one without any comments. From the perspective of the WHO document issued in 2009, the declaration of a swine flu pandemic in June 2009 seemed justified. However, considering the previous pandemic history, common sense, and the consequences of declaring a pandemic for a disease not accompanied by a high number of cases and high mortality, it was a premature move.Conclusion: Since the primary factor hindering the development of a pandemic is the effectiveness of treating infectious diseases, but not a definition of a pandemic, to minimize the likelihood of a new pandemic, it is necessary to improve the quality of special medical education and to study and adapt to modern conditions all effective drugs and methods used in the past.
... To this definition should be added the dynamic of contagion, for it is exactly this feature of the pandemic that implies the potential of overburdening institutions, hence creating time pressure for pandemic policies-a core criterion of crises in general. The term pandemic denotes a wide-ranging social constellation that arises through contagion, with specific consequences associated (Doshi 2011;Kelly 2011). Talk of a pandemic therefore has a performative effect, and in particular the public declaration of a constellation as a pandemic-for example by the World Health Organization-has political consequences. ...
Book
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The coronavirus pandemic has brought about a number of partly improvised, partly only temporary, but in every respect diverse and often unprecedented social policy measures in Europe. The edited volume provides an encompassing and longer-term analysis of social policy responses during the COVID-19 crisis in order to ask in which direction the European welfare states on the one hand, and EU social policy on the other hand, are developing as a result of the pandemic with respect to polity, politics, and policy instruments. The book focuses on the tension between continuity and change from different interdisciplinary and theoretical perspectives. Contributions range from single case studies to comparative policy analyses. The chapters in this book study (1) welfare state change during the pandemic in order to contribute to welfare state and regime theory; (2) policy responses in specific social policy domains, their socio-structural effects for particular social groups; and their potential future effects on the social security systems in different countries; and (3) social policymaking as a multilevel process, analyzing different crises responses and discussing the implications for European integration and EU social policy. Overall, the different social policy areas, European countries, and social groups studied in this volume show not only that the welfare state is here to stay, but also that social policy may potentially develop and expand its competences at the European level.
... To this definition should be added the dynamic of contagion, for it is exactly this feature of the pandemic that implies the potential of overburdening institutions, hence creating time pressure for pandemic policies-a core criterion of crises in general. The term pandemic denotes a wide-ranging social constellation that arises through contagion, with specific consequences associated (Doshi 2011;Kelly 2011). Talk of a pandemic therefore has a performative effect, and in particular the public declaration of a constellation as a pandemic-for example by the World Health Organization-has political consequences. ...
Chapter
Full-text available
The coronavirus pandemic has brought about a number of partly improvised, partly only temporary, but in every respect diverse and often unprecedented social policy measures in Europe. The edited volume provides an encompassing and longer-term analysis of social policy responses during the COVID-19 crisis in order to ask in which direction the European welfare states on the one hand, and EU social policy on the other hand, are developing as a result of the pandemic with respect to polity, politics, and policy instruments. The book focuses on the tension between continuity and change from different interdisciplinary and theoretical perspectives. Contributions range from single case studies to comparative policy analyses. The chapters in this book study (1) welfare state change during the pandemic in order to contribute to welfare state and regime theory; (2) policy responses in specific social policy domains, their socio-structural effects for particular social groups; and their potential future effects on the social security systems in different countries; and (3) social policymaking as a multilevel process, analyzing different crises responses and discussing the implications for European integration and EU social policy. Overall, the different social policy areas, European countries, and social groups studied in this volume show not only that the welfare state is here to stay, but also that social policy may potentially develop and expand its competences at the European level.
... Exceptionally deadly population dynamics in accordance with the WHO's before-2009 description of what should be classified as an ongoing pandemic (in 2003-2009 comprising the qualifier '… resulting in epidemics world-wide with enormous numbers of deaths and illness') [46][47][48] are not discernible for the years 2020 and 2021 in figures 4, 5 and tables 1, 2. Hence, data contradict a classification of C19 as an 'exceptionally severe disease' [49] or declaring its spread as a 'public health emergency of international concern' [50]. ...
Article
Full-text available
Counts of SARS-CoV-2-related deaths have been key numbers for justifying severe political, social and economical measures imposed by authorities world-wide. A particular focus thereby was the concomitant excess mortality (EM), i.e. fatalities above the expected all-cause mortality (AM). Recent studies, inter alia by the WHO, estimated the SARS-CoV-2-related EM in Germany between 2020 and 2021 as high as 200 000. In this study, we attempt to scrutinize these numbers by putting them into the context of German AM since the year 2000. We propose two straightforward, age-cohort-dependent models to estimate German AM for the ‘Corona pandemic’ years, as well as the corresponding flu seasons, out of historic data. For Germany, we find overall negative EM of about −18 500 persons for the year 2020, and a minor positive EM of about 7000 for 2021, unveiling that officially reported EM counts are an exaggeration. In 2022, the EM count is about 41 200. Further, based on NAA-test-positive related death counts, we are able to estimate how many Germans have died due to rather than with CoViD-19; an analysis not provided by the appropriate authority, the RKI. Through 2020 and 2021 combined, our due estimate is at no more than 59 500. Varying NAA test strategies heavily obscured SARS-CoV-2-related EM, particularly within the second year of the proclaimed pandemic. We compensated changes in test strategies by assuming that age-cohort-specific NAA-conditional mortality rates during the first pandemic year reflected SARS-CoV-2-characteristic constants.
... The pandemic usually spreads worldwide and crosses international borders, infecting a large number of persons (Kelly, 2011). However, developing a precise definition of the term 'pandemic" has proved difficult and the usual practice is to describe it (Doshi, 2011). After studying the key features of various pandemic diseases like plague, SARS, AIDS, etc. the following characteristics that can be used to describe a pandemic has been identified (Morens, Folkers, & Fauci, 2009): ...
Chapter
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Peace, justice and strong institutions' is one of the 17 Sustainable Development Goals established by the United Nations in 2015. The pandemic has affected the functioning of several institutions, including the judiciary and access to justice has been directly or indirectly hampered. The COVID-19 pandemic has affected the functioning of the courts. Courts have closed down or reduced their operations. This has negatively impacted the provision of timely and fair hearings. It has contributed to increased case backlogs, and lead to increased length of judicial and administrative proceedings. A complete shut-down of the justice-delivery system is undesirable, for this the judicial administrators have adjusted their operations. For modifying their operations they have turned to technology to meet the challenges posed by the pandemic. Various judicial and quasi�judicial bodies, led by the Supreme Court, have been conducting hearings online. An effective judicial system becomes important during an emergency. As the state enacts emergency regulations to counter the spread of COVID-19, judicial oversight of the implementation of emergency measures is critical to avoid the excessive use of emergency powers. The socio-economic impact of the crisis will also have significant justice-related implications on different sections of society and the economy. Targeted efforts by the judiciary will be required to help the sections of the society which have been impacted negatively. Persistent judicial efforts will be required to improve access to legal services and legal information to empower people and communities to resolve their disputes, seek redress for rights violations. In this paper, we look into the challenges faced by the judiciary and their responses to the COVID-19 pandemic.
... Pandemics are for the most part disease outbreaks that become widespread as a result of the spread of human-to-human infection (Doshi, P, 2011). Beyond the debilitating, sometimes fatal consequences for those directly affected, pandemics have a range of negative social, economic and political consequences. ...
... The WHO declarations of PHEICs are, notably, also connected to acuteness or political commitment (Wilder-Smith and Osman 2020), as global reactions to declaring polio a PHEIC differed from the declaration of Ebola as a PHEIC in 2014 (which differed from the response to the 2019 Ebola PHEIC declaration). There is also evidence that the legal instrument of PHEIC declarations under the IHR attracts less global attention than the less-legalistic declaration of a global 'pandemic' (Doshi 2011;Green 2020). Emergency terminologies (McConnell 2020) generally have a limited temporal and spatial scope, meaning events vary in how compatible they are with crisis frames, and definitional power plays a significant role. ...
Article
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In this article, we consider the role that onset patterns play in shaping how acute global events are taken to be, drawing on illustrative cases from the field of global health emergencies. We identify four temporal manifestation patterns that we argue display distinct political dynamics. First, an emergent onset pattern (e.g. the H1N1 health emergency), with political dynamics dominated by novelty-induced uncertainty and lack of information as well as familiar analogies. Second, an anticipatory onset pattern (e.g. the risk of a global avian flu health emergency), with a political dynamic characterised by dread of an as-of-yet unrealised high-consequence risk. Third, a cyclical onset pattern (e.g. Ebola), with a political dynamic characterised by a sense of familiarity and expect-edness, unless eventual 'unexpected' or 'unprecedented' aspects manifest themselves. Lastly, a perpetual onset pattern (e.g. antimicrobial resistance), with political dynamics characterised by incrementalism and low political salience. We argue that acuteness is often associated with a departure from expected manifestation patterns, such as an escalation or other traits that make events appear unfamiliar. Whilst drawing on global health emergences in this paper, the four categories theorised here may also be used on a range of other adversities at the global or local level.
... Zur WHO und ihrer Finanzierung, Organisation sowie Pandemiepolitik siehe kritisch: Beigbeder 2012;Doshi 2011;Meisterhans 2020 ...
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Im Ausnahmezustand der ‚Corona-Krise‘ konzentrierte sich die politische Macht bei der Exekutive und demokratische Freiheits- und Teilhaberechte sowie rechtsstaatliche Kontrollen wurden massiv eingeschränkt oder außer Kraft gesetzt. Dabei zeichnet sich ein neuartiger krisenbedingter technokratischer Autoritarismus ab, der politisch nicht (wie traditionell) von rechts kommt, sondern eher von links, unter den Zeichen des vermeintlich ‚Guten‘ und ‚Wahren‘. Diese Art von Autoritarismus ist wissenschaftlich kaum erforscht, sowohl bezüglich der Konzeptualisierung und Messung wie auch von Vorkommen, Entwicklung und Hintergrund. In der ‚Corona-Krise‘ kulminierte eine seit langem währende Krisenpolitik vermeintlicher ‚Alterna-tivlosigkeit‘, mit der Erosion der Demokratie und Spaltung der Gesellschaft entlang ‚symbolischen Kapitals‘. Angesichts immer neuer Krisenkonstruktionen wie der ‚Klimakrise‘ und der Popularität technokratisch-autoritärer Haltungen sind Forschungen dazu auch demokratietheoretisch geboten. Im Beitrag wird zunächst kursorisch die Entwicklung des krisenbedingten Autoritarismus in der ‚Corona-Krise‘ rekapituliert. Dann folgen Überlegungen zum Konzept des wenig erforschten linken, technokratischen Autoritarismus, dessen Relevanz durch die danach referierten Studien zum Hintergrund autoritärer Tendenzen in der ‚Corona-Krise‘ unterstrichen wird. Abschließend folgt ein Fazit mit dem Ausblick auf die weitere Forschung.
... Pandemics are typically more severe and geographically extensive than localized outbreaks and tend to be caused by novel pathogens and affect more than one country, continent, or the whole world relatively simultaneously (Dimka et al., 2022). They are regularly occurring phenomena through history, although the definition of a pandemic is not standard across fields (e.g., Doshi, 2011). The 1918 influenza pandemic is often considered a worst-case scenario for an acute respiratory outbreak with estimated death counts ranging from 15-40 million, or even 50-100 million (Crosby, 1989;Johnson & Mueller, 2002;Patterson & Pyle, 1991;Spreeuwenberg et al., 2018). ...
Article
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Research on the 1918 influenza pandemic often focuses exclusively on pandemic years, reducing the potential long‐term insights about the pandemic. It is critical to frame the 1918 pandemic within the underlying population dynamics, health, and sociocultural context to understand what factors contributed to pandemic mortality and survivorship, with respect to observed inequality, and consequences of the pandemic. Individual death records and censuses from The Rooms Provincial Archives and Memorial University of Newfoundland Digital Archives for three major causes of death—influenza and pneumonia; tuberculosis; and pooled bronchitis, measles, and whooping cough—were collected for three periods in the early 20th century: pre‐pandemic (1909–11), pandemic (March 1918–Janaury 1919), and post‐pandemic (1933–1935). We calculated pooled age‐standardized mortality rates and changes in pre‐ to post‐pandemic mortality rates by region. We fit Kaplan–Meier and Cox proportional hazards models to each period, controlling for age, cause of death, and region. Pandemic mortality was higher than that of pre‐ and post‐pandemic periods. Post‐pandemic mortality was significantly lower than pre‐pandemic mortality in all regions, except Western Newfoundland. Survival was lowest during the pandemic and increased significantly post‐pandemic (p < 0.0001), with no significant differences among regions during the pandemic (p = 0.32). Significant differences in survivorship in 1933–1935 were driven by increasing differences in survivorship for P&I among the regions more than other causes of death. Myopic perspectives of pandemics can obscure our understanding of observed outcomes. Inequalities in respiratory disease mortality are evident in pre‐ and post‐pandemic periods, but these would have been missed in investigations of the pandemic period alone.
... Influenza-Virus (Schweinegrippe) 2009 und dem damit einhergehenden internationalen Diskurs zwischen nationalen und globalen Gesundheitsinstitutionen, wie beispielsweise der WHO, Politiker:innen und Medienvertreter:innen, wurde bereits vor der COVID-19-Pandemie ersichtlich, dass keine einheitliche Definition des Begriffs Pandemie existiert (Barnett, 2011;Doshi, 2011;Kelly, 2011;Morens et al., 2009;Singer et al., 2021), was nachfolgende Zitate ersichtlich machen sollen: ...
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Sufficient studies are currently available that summarize and compare the mental health of the population and hospital staff during the COVID-19 pandemic, but mostly insufficiently compare them with the time before the pandemic. There is currently no study that compares the mental health of the population and hospital staff of a country internationally during and before the pandemic. In this work, (1) the mental health (stress, depression, anxiety, mental well-being, mental quality of life) of Austrian hospital staff is empirically assessed using questionnaires (PSS-10, PHQ-9, GAD-7, WHO-5, WHOQOL-BREF), compared to an Austrian population sample and checked for differences. The Austrian hospital staff (N= 1.037) differs significantly from the Austrian population in all outcomes (stress ↑, depression ↑, quality of life ↑, anxiety ↓, mental well-being ↓), except for the degree of insomnia, with a small effect size (Hedges g: -0.33-0.02). The results were then (2) compared internationally and to the pre-pandemic period using a systematic literature review. The mental health of the Austrian (stress ↑, depression ↑, anxiety ↑, quality of life ↓) and global (depression ↑, anxiety ↑, insomnia ↑) population, as well as of hospital staff (depression ↑, anxiety ↑) has worsened in all comparable outcomes compared to the time before the pandemic. In an international comparison, the Austrian population has shown better mental health in the period of the pandemic so far (depression ↓, anxiety ↓). In an international comparison, the Austrian hospital staff is less anxious in times of high stress, with a similar prevalence of depression and insomnia. The results should be interpreted with caution due to the lack of representativeness. For the Austrian population and hospital staff, it will be essential in the future that mental health is promoted more, that the taboo on mental treatment is broken and that outpatient and inpatient mental care is significantly expanded.
... There were two opposing sides. One claimed the WHO had changed the definition of the term to quickly declare a pandemic; the other argued that a definition was never formally defined [180]. Regarding the 2009 novel H1N1 influenza, pandemic was declared related to four aspects of the virus. ...
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Fear-responses to bat-originating coronavirus pandemics with respect to quarantine imposition are gathered and interpreted from large datasets, identified and disseminated by media. Responses are effectively gauged using postmodern thought with a continuum ranging from people’s resilience to define their own perspectives to public views being socially conditioned from media persistence in maintaining fear. Public responses to the 2003 SARS pandemic generally presumed and supported resilience of citizens’ perspectives. In contrast, from late 2019 to mid-2022, public responses to the COVID-19 pandemic were media-determined, promoting fear. In this regard, reactions to the COVID-19 quarantines are contrasted to the hospital isolations of SARS. The primary source of the difference was the major polarizing influence by social media of the WHO policy makers’ pronouncements and of healthcare providers’ statements directing media spotlight in their guidance of public response to COVID-19 throughout the pandemic, unlike during SARS. An investigation of cognitive bias regarding the psychological and societal implications related to this migration from resilience to fear regarding public responses to novel bat-originating coronavirus pandemics elicits recommendations concerning future quarantine dictates. These recommendations are dependent on appropriate encouragement of hopeful resilience through evidence based practice with respect to one extreme of the postmodern thought continuum.
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Zeitschrift für kritische Gesellschaftsforschung, siehe: https://cdoi.org/1.1/064/000062
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Water supply and access has gained widespread attention especially with the ongoing coronavirus pandemic. Summations from the documents show that the pandemic has led to investors holding out on channeling funds into water systems in Paraguay, thus leaving people in rural areas being unable to gain basic protection against the virus. The challenges faced are explored in the subsequent systematic review. Results show that Paraguay has a more than functional water system, which can, however, be improved through collaboration between private and government entities. Recommendations drawn call on the involvement of all stakeholders in decision making to find an iron-clad solution to the issue.
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In pandemics, past and present, there is no textbook definition of when a pandemic is over, and how and when exactly a respiratory virus transitions from pandemic to endemic spread. In this paper we have compared the 1918/19 influenza pandemic and the subsequent spread of seasonal flu until 1924. We analysed 14,125 reports of newly stated 32,198 influenza-like illnesses from the Swiss canton of Bern. We analysed the temporal and spatial spread at the level of 497 municipalities, 9 regions, and the entire canton. We calculated incidence rates per 1000 inhabitants of newly registered cases per calendar week. Further, we illustrated the incidences of each municipality for each wave (first wave in summer 1918, second wave in fall/winter 1918/19, the strong later wave in early 1920, as well as the two seasonal waves in 1922 and 1924) on a choropleth map. We performed a spatial hotspot analysis to identify spatial clusters in each wave, using the Gi* statistic. Furthermore, we applied a robust negative binomial regression to estimate the association between selected explanatory variables and incidence on the ecological level. We show that the pandemic transitioned to endemic spread in several waves (including another strong wave in February 1920) with lower incidence and rather local spread until 1924 at least. At the municipality and regional levels, there were different patterns of spread both between pandemic and seasonal waves. In the first pandemic wave in summer 1918 the probability of higher incidence was increased in municipalities with a higher proportion of factories (OR 2.60, 95%CI 1.42-4.96), as well as in municipalities that had access to a railway station (OR 1.50, 95%CI 1.16-1.96). In contrast, the strong fall/winter wave 1918 was very widespread throughout the canton. In general, municipalities at higher altitude showed lower incidence. Our study adds to the sparse literature on incidence in the 1918/19 pandemic and subsequent years. Before Covid-19, the last pandemic that occurred in several waves and then became endemic was the 1918-19 pandemic. Such scenarios from the past can inform pandemic planning and preparedness in future outbreaks.
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Purpose This study aims to highlight the moderating role of perceived organizational, supervisory and coworker’s support in weakening the negative relationship between fear of pandemic (FOP) and employee’s engagement in the Asian organizations. Furthermore, this study also aims to explore the role of employees’ engagement as an intervening mechanism, which mediates the relationship between FOP and employee’s performance in an Asian postpandemic context. Design/methodology/approach Based on extensive review of recent literature and sound theoretical reasoning, the authors have developed a comprehensive conceptual framework (with related theoretical propositions) which provides clear guidelines as to how Asian Business Managers/organizations can minimize the adverse effect of the employee’s fear triggered by the pandemic at the workplace and how provision of effective and timely organizational/interpersonal support (i.e. organizational, managerial and coworkers level support) can help Asian Managers address various workplace challenges created by the pandemic moving forward. This study has further validated the proposed conceptual framework and related theoretical propositions by conducting an in-depth bibliometric analysis and by developing clusters of the co-occurrences based on most recent/ relevant literature published in the area. Findings This study advances the knowledge in the areas of FOP and organizational support in particular. A comprehensive review of the literature clearly indicates how effective organizational, supervisory and peer support mechanism can help Asian Business Managers in alleviating the negative impact of the FOP on various employee level outcomes such as employees “engagement and performance” and how it can help Asian firms in addressing the associated challenges while working in a postpandemic context. Later on, an in-depth bibliometric analysis of the literature has revealed emerging knowledge patterns in the field and has indicated several key gaps in the existing literature which further confirms the theoretical framework and the propositions related thereto. Originality/value Though several researchers have previously examined the fear created by COVID-19 at workplace, relatively fewer researchers have tried to link it up with employees’ level of involvement/ engagement at workplace. Even fewer researchers have tried to examine the vital role that organizational, managerial and peers support can play in minimizing the adverse effects created by pandemic-induced fears for employees’ productivity and performance in an Asian workplace context. Furthermore, hardly any efforts have been made to look at this popular notion of employees’ engagement as an intervening mechanism which carries a significant potential to mediate the relationship between FOP and employees’ job performance. This study aims to bridge all these gaps by integrating the two main streams of knowledge together, i.e. Four Horsemen of Fear and Organizational Support theory. Based on strong theoretical reasoning, an in-depth review and a bibliometric analysis of the relevant literature, the authors have developed a comprehensive conceptual framework which explains how various levels of support may interact with FOP to predict different levels of employees’ engagement in a contemporary Asian workplace and how this in turn may impact employees’ job performance while at work.
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From Managing the Pandemic Crisis to Syndemic Governance: A Conceptual Reframing of Syndemics in the Context of Influenza Pandemics As a result of the COVID-19 pandemic, the research literature has highlighted the significance of syndemic thinking in managing epidemics (e.g. Horton 2020; Irons 2020; Fronteira et al. 2021). The syndemic nature of COVID-19 has posed a challenge to traditional models of management that promote path dependence, which in turn fuels more emergent effects. As a result, many causal relationships cannot be fully mapped in real time, making syndemic interventions challenging to implement. This article introduces new conceptualizations of syndemics by applying theories of emergent governance in order to develop a model of syndemic governance. In this context, emergence emphasizes the forms of interaction between components of complex systems that generate problems that cannot be traced back to these components and their functioning alone. These forms of interaction arise through self-organization...
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El objetivo de este trabajo es realizar una reflexión crítica sobre la idea de un mundo postpandemia, a partir de la deconstrucción de genealogías discursivas sobre la pandemia de la covid-19. Se utilizó como punto de partida la idea de Michel Foucault de historia del presente, en términos de la deconstrucción de los relatos que dan cuenta tanto lo novedoso, en esta caso de la pandemia de la covid-19, como de las inercias discursivas del pasado que perviven en el presente. Se deconstruyeron cinco genealogía discursivas sobre pandemia. En primer lugar, se abordó el problema de la propia definición de pandemia, a partir de la crisis de la gripe A, gripe porcina o H1N1. En segundo lugar, se reflexionó sobre el impacto que tuvo la gestión de la crisis del H1N1 en las representaciones y prácticas discursivas de la pandemia de covid-19. En tercer lugar, se discutieron los marcos interpretativos y epistemológicos del gobierno de las crisis pandémicas en las sociedades del Norte Global. Por su interés discursivo se analizaron, por una parte, la construcción discursiva del gobierno de las epidemias, considerando las ideas de confinamiento y vacunación y, por otra parte, el gobierno de las infraestructuras vitales, como origen de la utilización metáfora de la guerra para el gobierno de riesgos y amenazas. En cuarto lugar, se reflexionará sobre el discurso de la (in)seguridad y sus dificultades pragmáticas en el gobierno de este tipo de crisis. Se utilizará la idea de la disonancia pragmática para dar cuenta de los problemas del discurso de la seguridad. En quito lugar, se criticó el discurso de la salud global y sus implicaciones en esta crisis, tomando como referencia tres relatos o narrativas: el relato sobre la seguridad en salud global, el relato sobre el mercado de productos sensibles, como los equipos de protección personal (mascarillas) y el relato sobre la producción de vacunas. A partir de la deconstrucción de estas genealogías discursivas plantearemos, a manera de conclusión, la idea de la crónica de un fracaso global, en relación con el gobierno de la crisis de la covid-19, agravada por la irrupción de una nueva crisis, la guerra de Ucrania. Proponemos finalmente una reconstrucción del discurso virus-céntrico, a partir de la idea de una espacialidad territorial y simbólicamente constituida organizada, configurada y materializada por múltiples tecnologías de significación, vinculadas bajo la figura de una red de actores propuesta por Bruno Latour.
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The opioid crisis in the United States (US) is one of the most high-profile public health scandals of the 21st century with millions of people unknowingly becoming dependent on opioids. The United Kingdom (UK) had the world’s highest rate of opioid consumption in 2019, and opiate-related drug poisoning deaths have increased by 388% since 1993 in England and Wales. This article explores the epidemiological definitions of public health emergencies and epidemics in the context of opioid use, misuse, and mortality in England, to establish whether England is facing an opioid crisis.
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A questão das doenças emergentes infecciosas e sua propagação é um tema mais urgente na atualidade do que em qualquer outra ocasião, tendo em vista a pandemia da COVID-19. Este trabalho propõe comparar a propagação de diferentes viroses emergentes, pandêmicas e epidêmicas. Avaliar a influência das ações antrópicas e do comportamento humano nestes processos, além de caracterizar os principais vetores nas viroses emergentes. Isto foi feito por meio de ampla revisão bibliográfica sobre o tema, abarcando publicações do final dos anos 1980 até 2020. Conclui-se que as modificações antrópicas associadas à agricultura intensiva fazem com que vetores se tornem sinantrópicos. A expansão em áreas novas provoca a entrada em nichos onde novos agentes podem ser encontrados. A criação extensiva porco–pato tradicionalmente praticada na China, coloca duas espécies em contato, favorecendo um laboratório natural para novas cepas recombinantes para gripe. No fator comportamento humano a facilidade de deslocamento, principalmente o transporte aéreo internacional, globalização, contribuem muito para rápida disseminação das doenças. Os resultados dessa pesquisa reforçam que a emergência das viroses está diretamente relacionada a fatores comportamentais humano e as ações antrópicas.
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Purpose. The word ‘pandemic’ reminds us of the disaster it has created in the world. The present paper aims to explore the gender-based difference in happiness levels among students of Indian higher education institutions (HEIs) during the pandemic. The study elaborates on the skill to remain happy by providing a happiness model useful in curriculum modification in HEIs for better learning of students. Design/ methodology. A self-constructed questionnaire was used to collect data from 642 respondents through purposive sampling. SPSS software was used for data analysis. Such statistical methods as independent t-test, multiple regression, and AMOS were employed for structural equation modelling. Findings. The statistical results showed no significant difference in the levels of happiness between the male and female students. Physical, psychological, social, and financial factors and semester stress were found to contribute to the happiness of students, and gender had a significant impact on physical, financial, and semester stress. Finally, a happiness model was developed. Originality. This research presents a model with five major contributing factors to happiness during the pandemic for students in Indian HEIs. The impact of gender on overall happiness and its contributing factors were also studied. Research limitation. The study should be expanded in terms of data collection, reaching more regions of India and outside to generalise the results. Practical implication. The outcomes that emerged from the study can be incorporated into the curriculum to prioritise happiness and improve students’ learning. Social Implication. A modified curriculum will help students to remain happy which automatically increases learning.
Article
In this paper, the author examines the logical and ontological aspects of pandemic. Relatedly, the the definition of a pandemic is scrutinized. The very word pandemic (????????) comes from the Classical Greek language and refers to something pertains to all (???) people (?????). However, this cannot be of great use for the definition of pandemic, because with each one known so far, it was about a wide distribution in the people, and not about the entire people. We will try to show that a precise definition (or precise description) of the pandemic does not exist, which means that the very notion is not clear, and therefore the declaration of a pandemic is a matter of preference of those who declare it. ?Wide distribution? is a wide notion that could be a part of acceptable scientific definition. Such a lack is, however, compensated by the frequent use of emotional determinants that only obscure the problem, instead of illuminating it. Expressions such as: ?invisible enemy?, ?social distancing?, ?new normal?, ?responsibility?, ?solidarity?, ?state of war?, ?virus attack? and others, have an emotional function, the goal of which is to replace the scientific, rational understanding of things.
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As of March 2020, counts of SARS-CoV-2-related ('CoViD-19') deaths have been key numbers for justifying severe political, social, and economical measures put into action by authorities world-wide. A particular focus thereby was the concomitant excess mortality (EM), i.e. fatalities above the normally expected all-cause mortality (AM). Recent reports and studies, inter alia by the WHO, estimated the SARS-CoV-2-related EM in Germany between 2020 and 2021 as high as 200,000. In this study, we attempt to scrutinise these numbers by putting them into the context of German AM since the year 2000. To this end, we propose two straightforward, low-parametric models to estimate German AM, and thus EM, for the years 2020 and 2021 as well as the flu seasons 2020/21 and 2021/22. Additionally, we give a forecast of the AM expected in 2022. After having derived age-cohort-specific mortality rates out of historical data, weighted with their corresponding demographic proportion, EM is obtained by subtracting (model-)calculated AM counts from observed ones. For Germany, we find even an overall negative EM ('under-mortality') of about -18,500 for the year 2020, and a minor positive EM of about 7,000 for 2021, unveiling that officially communicated EM numbers are a great exaggeration. Further, putting CoViD-19 "cases" (defined by positive PCR test outcomes) and their related death counts into the context of AM, we are able to estimate how many Germans have died due to rather than with CoViD-19; an analysis not provided by the appropriate authority, the RKI. Thereby, varying governmental PCR test strategies are shown to heavily obscure reliable estimations of SARS-CoV-2-related EM, particularly within the second year of the proclaimed pandemic.
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Pandemics reverberated their times, changing social and economic contexts, prompting, and redirecting changes in social ties, business, and education, restructuring the world that generated them. In this context, this study aims to assess the impact of the COVID-19 pandemic on the global energy matrix, supported by an analysis of consumption, demand, and GDP from January 2019 to June 2021. The energy balance showed variations in this period, with impacts on the environment. We will assess whether the changes will be lasting.
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More than a year after an influenza pandemic was declared in June 2009, the World Health Organization declared the pandemic to be over. Evaluations of the pandemic response are beginning to appear in the public domain. We argue that, despite the enormous effort made to control the pandemic, it is now time to acknowledge that many of the population-based public health interventions may not have been well considered. Prior to the pandemic, there was limited scientific evidence to support border control measures. In particular no border screening measures would have detected prodromal or asymptomatic infections, and asymptomatic infections with pandemic influenza were common. School closures, when they were partial or of short duration, would not have interrupted spread of the virus in school-aged children, the group with the highest rate of infection worldwide. In most countries where they were available, neuraminidase inhibitors were not distributed quickly enough to have had an effect at the population level, although they will have benefited individuals, and prophylaxis within closed communities will have been effective. A pandemic specific vaccine will have protected the people who received it, although in most countries only a small minority was vaccinated, and often a small minority of those most at risk. The pandemic vaccine was generally not available early enough to have influenced the shape of the first pandemic wave and it is likely that any future pandemic vaccine manufactured using current technology will also be available too late, at least in one hemisphere. Border screening, school closure, widespread anti-viral prophylaxis and a pandemic-specific vaccine were unlikely to have been effective during a pandemic which was less severe than anticipated in the pandemic plans of many countries. These were cornerstones of the population-based public health response. Similar responses would be even less likely to be effective in a more severe pandemic. We agree with the recommendation from the World Health Organisation that pandemic preparedness plans need review.
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Understanding immunity, incidence and risk factors of the 2009 influenza A(H1N1) pandemic (2009 H1N1) through a national seroprevalence study is necessary for informing public health interventions and disease modelling. We collected 1687 serum samples and individual risk factor data between November-2009 to March-2010, three months after the end of the 2009 H1N1 wave in New Zealand. Participants were randomly sampled from selected general practices countrywide and hospitals in the Auckland region. Baseline immunity was measured from 521 sera collected during 2004 to April-2009. Haemagglutination inhibition (HI) antibody titres of ≥1:40 against 2009 H1N1 were considered seroprotective as well as seropositive. The overall community seroprevalence was 26.7% (CI:22.6-29.4). The seroprevalence varied across age and ethnicity. Children aged 5-19 years had the highest seroprevalence (46.7%;CI:38.3-55.0), a significant increase from the baseline (14%;CI:7.2-20.8). Older adults aged ≥60 had no significant difference in seroprevalence between the serosurvey (24.8%;CI:18.7-30.9) and baseline (22.6%;CI:15.3-30.0). Pacific peoples had the highest seroprevalence (49.5%;CI:35.1-64.0). There was no significant difference in seroprevalence between both primary (29.6%;CI:22.6-36.5) and secondary healthcare workers (25.3%;CI:20.8-29.8) and community participants. No significant regional variation was observed. Multivariate analysis indicated age as the most important risk factor followed by ethnicity. Previous seasonal influenza vaccination was associated with higher HI titres. Approximately 45.2% of seropositive individuals reported no symptoms. Based on age and ethnicity standardisation to the New Zealand Population, about 29.5% of New Zealanders had antibody titers at a level consistent with immunity to 2009 H1N1. Around 18.3% of New Zealanders were infected with the virus during the first wave including about one child in every three. Older people were protected due to pre-existing immunity. Age was the most important factor associated with infection followed by ethnicity. Healthcare workers did not appear to have an increased risk of infection compared with the general population.
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Assessment of the severity of disease due to the 2009 pandemic influenza A(H1N1) in Australian states and territories has been hampered by the absence of denominator data on population exposure. We compared antibody reactivity to the pandemic virus using haemagglutination inhibition assays performed on plasma specimens taken from healthy adult blood donors (older than 16 years) before and after the influenza pandemic that occurred during the southern hemisphere winter. Pre-influenza season samples (April – May 2009, n=496) were taken from donation collection centres in North Queensland (in Cairns and Townsville); post-outbreak specimens (October – November 2009, n=779) were from donors at seven centres in five states. Using a threshold antibody titre of 40 as a marker of recent infection, we observed an increase in the influenza-seropositive proportion of donors from 12% to 22%, not dissimilar to recent reports of influenza A(H1N1)-specific immunity in adults from the United Kingdom. No significant differences in seroprevalence were observed between Australian states, although the ability to detect minor variations was limited by the sample size. On the basis of these figures and national reporting data, we estimate that approximately 0.23% of all individuals in Australia exposed to the pandemic virus required hospitalisation and 0.01% died. The low seroprevalence reported here suggests that some degree of prior immunity to the virus, perhaps mediated by broadly reactive T-cell responses to conserved influenza viral antigens, limited transmission among adults and thus constrained the pandemic in Australia.
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The clinical characteristics of pandemic 2009 influenza A(H1N1) infections have not been compared directly with illnesses caused by other influenza A strains. To compare clinical features and outcomes for 2009 H1N1, seasonal H1N1, and H3N2 influenza in a population-based cohort. Active surveillance with 30-day follow-up for influenza cases among children and adults living in a 14-zip code area in Wisconsin. Patients with subjective fever, chills, or cough of fewer than 8 days' duration were screened for eligibility during an outpatient or inpatient encounter. Consenting patients were interviewed and tested for influenza A during the 2007-2008 and 2008-2009 influenza seasons and from May to November 2009; 6874 patients (70%-86% of eligible patients) agreed to participate. Medical records were reviewed to assess outcomes. Hospital admission, radiographically confirmed pneumonia, and clinical characteristics of influenza A by strain. We identified 545 2009 H1N1, 221 seasonal H1N1, and 632 H3N2 infections. The median ages of infected participants were 10, 11, and 25 years, respectively (P < .001). Hospital admission occurred within 30 days for 6 of 395 children with 2009 H1N1 (1.5%; 95% confidence interval [CI], 0.6%-3.1%), 5 of 135 with seasonal H1N1 (3.7%; 95% CI, 1.4%-8.0%), and 8 of 255 with H3N2 (3.1%; 95% CI, 1.5%-5.9%). Among adults, hospital admission occurred in 6 of 150 with 2009 H1N1 (4.0%; 95% CI, 1.6%-8.1%), 2 of 86 with seasonal H1N1 (2.3%; 95% CI, 0.3%-8.1%), and 17 of 377 with H3N2 (4.5%; 95% CI, 2.7%-7.0%). Pneumonia occurred in 10 children with 2009 H1N1 (2.5%; 95% CI, 1.3%-4.5%), 2 with seasonal H1N1 (1.5%; 95% CI, 0.2%-5.2%), and 5 with H3N2 (2.0%; 95% CI, 0.7%-4.3%). Among adults, pneumonia occurred in 6 with 2009 H1N1 (4.0%; 95% CI, 1.6%-8.1%), 2 with seasonal H1N1 (2.3%; 95% CI, 0.3%-8.1%), and 4 with H3N2 (1.1%; 95% CI, 0.3%-2.7%). In this population, individuals with 2009 H1N1 infection were younger than those with H3N2. The risk of most serious complications was not elevated in adults or children with 2009 H1N1 compared with recent seasonal strains.
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We compared confirmed pandemic (H1N1) 2009 influenza and seasonal influenza diagnosed in Western Australia during the 2009 influenza season. From 3,178 eligible reports, 984 pandemic and 356 seasonal influenza patients were selected; 871 (88.5%) and 288 (80.9%) were interviewed, respectively. Patients in both groups reported a median of 6 of 11 symptoms; the difference between groups in the proportion reporting any given symptom was < or =10%. Fewer than half the patients in both groups had > or =1 underlying condition, and only diabetes was associated with pandemic (H1N1) 2009 influenza (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.1-3.5). A total of 129 (14.8%) persons with pandemic (H1N1) 2009 and 36 (12.5%) persons with seasonal influenza were hospitalized (p = 0.22). After controlling for age, we found that patient hospitalization was associated with pandemic (H1N1) 2009 influenza (OR 1.5; 95% CI 1.1-2.1). Contemporaneous pandemic and seasonal influenza infections were substantially similar in terms of patients' symptoms, risk factors, and proportion hospitalized.
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Background: Planning for the treatment of infection with the 2009 pandemic influenza A (H1N1) virus through health care systems in developed countries during winter in the Northern Hemisphere is hampered by a lack of information from similar health care systems. Methods: We conducted an inception-cohort study in all Australian and New Zealand intensive care units (ICUs) during the winter of 2009 in the Southern Hemisphere. We calculated, per million inhabitants, the numbers of ICU admissions, bed-days, and days of mechanical ventilation due to infection with the 2009 H1N1 virus. We collected data on demographic and clinical characteristics of the patients and on treatments and outcomes. Results: From June 1 through August 31, 2009, a total of 722 patients with confirmed infection with the 2009 H1N1 virus (28.7 cases per million inhabitants; 95% confidence interval [CI], 26.5 to 30.8) were admitted to an ICU in Australia or New Zealand. Of the 722 patients, 669 (92.7%) were under 65 years of age and 66 (9.1%) were pregnant women; of the 601 adults for whom data were available, 172 (28.6%) had a body-mass index (the weight in kilograms divided by the square of the height in meters) greater than 35. Patients infected with the 2009 H1N1 virus were in the ICU for a total of 8815 bed-days (350 per million inhabitants). The median duration of treatment in the ICU was 7.0 days (interquartile range, 2.7 to 13.4); 456 of 706 patients (64.6%) with available data underwent mechanical ventilation for a median of 8 days (interquartile range, 4 to 16). The maximum daily occupancy of the ICU was 7.4 beds (95% CI, 6.3 to 8.5) per million inhabitants. As of September 7, 2009, a total of 103 of the 722 patients (14.3%; 95% CI, 11.7 to 16.9) had died, and 114 (15.8%) remained in the hospital. Conclusions: The 2009 H1N1 virus had a substantial effect on ICUs during the winter in Australia and New Zealand. Our data can assist planning for the treatment of patients during the winter in the Northern Hemisphere.
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To establish mortality from pandemic A/H1N1 2009 influenza up to 8 November 2009. Investigation of all reported deaths related to pandemic A/H1N1 in England. Mandatory reporting systems established in acute hospitals and primary care. Physicians responsible for the patient. Numbers of deaths from influenza combined with mid-range estimates of numbers of cases of influenza to calculate age specific case fatality rates. Underlying conditions, time course of illness, and antiviral treatment. With the official mid-range estimate for incidence of pandemic A/H1N1, the overall estimated case fatality rate was 26 (range 11-66) per 100 000. It was lowest for children aged 5-14 (11 (range 3-36) per 100 000) and highest for those aged >or=65 (980 (range 300-3200) per 100 000). In the 138 people in whom the confirmed cause of death was pandemic A/H1N1, the median age was 39 (interquartile range 17-57). Two thirds of patients who died (92, 67%) would now be eligible for the first phase of vaccination in England. Fifty (36%) had no, or only mild, pre-existing illness. Most patients (108, 78%) had been prescribed antiviral drugs, but of these, 82 (76%) did not receive them within the first 48 hours of illness. Viewed statistically, mortality in this pandemic compares favourably with 20th century influenza pandemics. A lower population impact than previous pandemics, however, is not a justification for public health inaction. Our data support the priority vaccination of high risk groups. We observed delayed antiviral use in most fatal cases, which suggests an opportunity to reduce deaths by making timely antiviral treatment available, although the lack of a control group limits the ability to extrapolate from this observation. Given that a substantial minority of deaths occur in previously healthy people, there is a case for extending the vaccination programme and for continuing to make early antiviral treatment widely available.
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(H1N1) 2009, we built a probabilistic multiplier model that adjusts the count of laboratory-confirmed cases for each of the following steps: medical care seeking (A), specimen collection (B), submission of specimens for confirmation (C), laboratory detection of pandemic (H1N1) 2009 (D), and reporting of confirmed cases (E) (Figure). This approach has been used to calculate the underrecognized impact of foodborne illness in the United States (3). At each step, we identified a range of proportions observed in prior published studies and recent surveys and investigations of pandemic (H1N1) 2009. These include 2 unpublished community surveys on influenza-like illness (ILI) and health-seeking behavior, the 2007 Behavioral Risk Factor Surveillance Survey conducted in 10 Through July 2009, a total of 43,677 laboratory-confi
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A new pandemic influenza A (H1N1) virus has emerged, causing illness globally, primarily in younger age groups. To assess the level of preexisting immunity in humans and to evaluate seasonal vaccine strategies, we measured the antibody response to the pandemic virus resulting from previous influenza infection or vaccination in different age groups. Using a microneutralization assay, we measured cross-reactive antibodies to pandemic H1N1 virus (2009 H1N1) in stored serum samples from persons who either donated blood or were vaccinated with recent seasonal or 1976 swine influenza vaccines. A total of 4 of 107 persons (4%) who were born after 1980 had preexisting cross-reactive antibody titers of 40 or more against 2009 H1N1, whereas 39 of 115 persons (34%) born before 1950 had titers of 80 or more. Vaccination with seasonal trivalent inactivated influenza vaccines resulted in an increase in the level of cross-reactive antibody to 2009 H1N1 by a factor of four or more in none of 55 children between the ages of 6 months and 9 years, in 12 to 22% of 231 adults between the ages of 18 and 64 years, and in 5% or less of 113 adults 60 years of age or older. Seasonal vaccines that were formulated with adjuvant did not further enhance cross-reactive antibody responses. Vaccination with the A/New Jersey/1976 swine influenza vaccine substantially boosted cross-reactive antibodies to 2009 H1N1 in adults. Vaccination with recent seasonal nonadjuvanted or adjuvanted influenza vaccines induced little or no cross-reactive antibody response to 2009 H1N1 in any age group. Persons under the age of 30 years had little evidence of cross-reactive antibodies to the pandemic virus. However, a proportion of older adults had preexisting cross-reactive antibodies.
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The novel 2009 influenza A(H1N1) pandemic virus has been an unexpected trigger for pandemic preparedness plans in the United States and elsewhere.1 It is appropriate to ask how the novel virus might behave epidemiologically in coming months, including the possibility of multiple recurrences or “waves.” Spring circulation of the novel virus in the Northern Hemisphere at the end of the 2008-2009 influenza season inevitably has led to comparisons with events in 1918-1919, which in some settings were preceded and followed by outbreaks of respiratory illnesses. Some also believe that the 1918 pandemic began with a premonitory “herald wave,” a term related to an old hypothesis, which influenza and dengue fever appeared to have supported, that as new viruses begin to circulate in human populations they inevitably acquire mutations that increase transmissibility and virulence.2
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Archeo-epidemiologic research can clarify certain “signature features” of three previous influenza pandemics that should inform both national plans for pandemic preparedness and required international collaborations. Dr. Mark Miller and colleagues discuss characteristics that are frequently not considered in response plans.
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Twelve years ago (BMJ 1996;312:1553-4) the BMJ argued that health systems needed to be explicit about rationing and published articles describing different ways of rationing fairly. Here a clinician (doi:10.1136/bmj.a1846), two ethicists, and four health economists (doi:10.1136/bmj.a1872) discuss how their ideas have developed—and been put into practice—since then
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The fear appeal literature is examined in a comprehensive synthesis using meta-analytical techniques. The meta-analysis suggests that strong fear appeals produce high levels of perceived severity and susceptibility, and are more persuasive than low or weak fear appeals. The results also indicate that fear appeals motivate adaptive danger control actions such as message acceptance and maladaptive fear control actions such as defensive avoidance or reactance. It appears that strong fear appeals and high-efficacy messages produce the greatest behavior change, whereas strong fear appeals with low-efficacy messages produce the greatest levels of defensive responses. Future directions and practical implications are provided.
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Influenza poses a continuing public health threat in epidemic and pandemic seasons. The 1951 influenza epidemic (A/H1N1) caused an unusually high death toll in England; in particular, weekly deaths in Liverpool even surpassed those of the 1918 pandemic. We further quantified the death rate of the 1951 epidemic in 3 countries. In England and Canada, we found that excess death rates from pneumonia and influenza and all causes were substantially higher for the 1951 epidemic than for the 1957 and 1968 pandemics (by > or =50%). The age-specific pattern of deaths in 1951 was consistent with that of other interpandemic seasons; no age shift to younger age groups, reminiscent of pandemics, occurred in the death rate. In contrast to England and Canada, the 1951 epidemic was not particularly severe in the United States. Why this epidemic was so severe in some areas but not others remains unknown and highlights major gaps in our understanding of interpandemic influenza.
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The European Influenza Surveillance Scheme (EISS) has collected clinical and virological data on influenza since 1996 in an increasing number of countries. The EISS dataset was used to characterise important epidemiological features of influenza activity in Europe during eight winters (1999-2007). The following questions were addressed: 1) are the sentinel clinical reports a good measure of influenza activity? 2) how long is a typical influenza season in Europe? 3) is there a west-east and/or south-north course of peak activity ('spread') of influenza in Europe? Influenza activity was measured by collecting data from sentinel general practitioners (GPs) and reports by national reference laboratories. The sentinel reports were first evaluated by comparing them to the laboratory reports and were then used to assess the timing and spread of influenza activity across Europe during eight seasons. We found a good match between the clinical sentinel data and laboratory reports of influenza collected by sentinel physicians (overall match of 72% for +/- 1 week difference). We also found a moderate to good match between the clinical sentinel data and laboratory reports of influenza from non-sentinel sources (overall match of 60% for +/- 1 week). There were no statistically significant differences between countries using ILI (influenza-like illness) or ARI (acute respiratory disease) as case definition. When looking at the peak-weeks of clinical activity, the average length of an influenza season in Europe was 15.6 weeks (median 15 weeks; range 12-19 weeks). Plotting the peak weeks of clinical influenza activity reported by sentinel GPs against the longitude or latitude of each country indicated that there was a west-east spread of peak activity (spread) of influenza across Europe in four winters (2001-2002, 2002-2003, 2003-2004 and 2004-2005) and a south-north spread in three winters (2001-2002, 2004-2005 and 2006-2007). We found that: 1) the clinical data reported by sentinel physicians is a valid indicator of influenza activity; 2) the length of influenza activity across the whole of Europe was surprisingly long, ranging from 12-19 weeks; 3) in 4 out of the 8 seasons, there was a west-east spread of influenza, in 3 seasons a south-north spread; not associated with type of dominant virus in those seasons.
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The fear appeal literature is diverse and inconsistent. Existing fear appeal theories explain the positive linear results occurring in many studies, but are unable to explain the boomerang or curvilinear results occurring in other studies. The present work advances a theory integrating previous theoretical perspectives (i.e., Janis, 1967; Leventhal, 1970; Rogers, 1975, 1983) that is based on Leventhal's (1970) danger control/fear control framework. The proposed fear appeal theory, called the Extended Parallel Process Model (EPPM), expands on previous approaches in three ways: (a) by explaining why fear appeals fail; (b) by re‐incorporating fear as a central variable; and (c) by specifying the relationship between threat and efficacy in propositional forms. Specific propositions are given to guide future research.
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Key scientists advising the World Health Organization on planning for an influenza pandemic had done paid work for pharmaceutical firms that stood to gain from the guidance they were preparing. These conflicts of interest have never been publicly disclosed by WHO, and WHO has dismissed inquiries into its handling of the A/H1N1 pandemic as “conspiracy theories.” Deborah Cohen and Philip Carter investigate Watch the BMJ/The Bureau of Investigative Journalism's video on WHO and disclosure. This video has also appeared on Al Jazeera and guardian.co.uk. Next week marks the first anniversary of the official declaration of the influenza A/H1N1 pandemic. On 11 June 2009 Dr Margaret Chan, the director general of the World Health Organization, announced to the world’s media: “I have conferred with leading influenza experts, virologists, and public health officials. In line with procedures set out in the International Health Regulations, I have sought guidance and advice from an Emergency Committee established for this purpose. On the basis of available evidence, and these expert assessments of the evidence, the scientific criteria for an influenza pandemic have been met…The world is now at the start of the 2009 influenza pandemic.”It was the culmination of 10 years of pandemic preparedness planning for WHO—years of committee meetings with experts flown in from around the world and reams of draft documents offering guidance to governments. But one year on, governments that took advice from WHO are unwinding their vaccine contracts, and billions of dollars’ worth of stockpiled oseltamivir (Tamiflu) and zanamivir (Relenza)—bought from health budgets already under tight constraints—lie unused in warehouses around the world.A joint investigation by the BMJ and the Bureau of Investigative Journalism has uncovered evidence that raises troubling questions about how WHO managed conflicts of interest among the scientists who advised its pandemic planning, and about the …
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Reproduction numbers estimated from disease incidence data can give public health authorities valuable information about the progression and likely size of a disease outbreak. Here, we show that methods for estimating effective reproduction numbers commonly give overestimates early in an outbreak. This is due to many factors including the nature of outbreaks that are used for estimation, incorrectly accounting for imported cases and outbreaks arising in subpopulations with higher transmission rates. Awareness of this bias is necessary to correctly interpret estimates from early disease outbreak data.
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Background: Different types of influenza vaccines are currently produced worldwide. Vaccination of pregnant women is recommended internationally, while healthy adults are targeted in North America. Objectives: To identify, retrieve and assess all studies evaluating the effects (efficacy, effectiveness and harm) of vaccines against influenza in healthy adults, including pregnant women. Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 2), MEDLINE (January 1966 to May 2013) and EMBASE (1990 to May 2013). Selection criteria: Randomised controlled trials (RCTs) or quasi-RCTs comparing influenza vaccines with placebo or no intervention in naturally occurring influenza in healthy individuals aged 16 to 65 years. We also included comparative studies assessing serious and rare harms. Data collection and analysis: Two review authors independently assessed trial quality and extracted data. Main results: We included 90 reports containing 116 data sets; among these 69 were clinical trials of over 70,000 people, 27 were comparative cohort studies (about eight million people) and 20 were case-control studies (nearly 25,000 people). We retrieved 23 reports of the effectiveness and safety of vaccine administration in pregnant women (about 1.6 million mother-child couples).The overall effectiveness of parenteral inactivated vaccine against influenza-like illness (ILI) is limited, corresponding to a number needed to vaccinate (NNV) of 40 (95% confidence interval (CI) 26 to 128). The overall efficacy of inactivated vaccines in preventing confirmed influenza has a NNV of 71 (95% CI 64 to 80). The difference between these two values depends on the different incidence of ILI and confirmed influenza among the study populations: 15.6% of unvaccinated participants versus 9.9% of vaccinated participants developed ILI symptoms, whilst only 2.4% and 1.1%, respectively, developed laboratory-confirmed influenza.No RCTs assessing vaccination in pregnant women were found. The only evidence available comes from observational studies with modest methodological quality. On this basis, vaccination shows very limited effects: NNV 92 (95% CI 63 to 201) against ILI in pregnant women and NNV 27 (95% CI 18 to 185) against laboratory-confirmed influenza in newborns from vaccinated women.Live aerosol vaccines have an overall effectiveness corresponding to a NNV 46 (95% CI 29 to 115).The performance of one-dose or two-dose whole virion pandemic vaccines was higher, showing a NNV of 16 (95% CI 14 to 20) against ILI and a NNV of 35 (95% CI 33 to 47) against influenza, while a limited impact on hospitalisation was found (NNV 94, 95% CI 70 to 1022).Vaccination had a modest effect on time off work and had no effect on hospital admissions or complication rates. Inactivated vaccines caused local harms. No evidence of association with serious adverse events was found, but the harms evidence base was limited.The overall risk of bias in the included trials is unclear because it was not possible to assess the real impact of bias. Authors' conclusions: Influenza vaccines have a very modest effect in reducing influenza symptoms and working days lost in the general population, including pregnant women. No evidence of association between influenza vaccination and serious adverse events was found in the comparative studies considered in the review. This review includes 90 studies, 24 of which (26.7%) were funded totally or partially by industry. Out of the 48 RCTs, 17 were industry-funded (35.4%).
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In her editorial accompanying the feature on conflicts of interest at the World Health Organization,1 2 Godlee notes that it is “almost certainly true” that the mildness of the H1N1 pandemic, compared with the severity long expected from a virus like H5N1, has contributed to the current critical scrutiny of WHO’s decisions. As the editorial further states, this reality does not make it wrong to ask hard questions. We fully agree. Good investigative journalism brings problems, and their potential consequences, into sharp focus and identifies the need for remedial action. Potential conflicts of interest are inherent in any relationship between a normative and health development agency, such as WHO, and profit driven industry. WHO needs to establish, and enforce, stricter rules of engagement with industry, and we are doing so. However, let me be …
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Fuelled by public distrust, a season of inquiries has begun into how governments and public health agencies responded to the A/H1N1influenza pandemic. If these reviews are to be meaningful, they would do well to address the failures in communication both before and during the pandemic that helped create this public distrust. The principle failure was this: instead of using the tools and principles of risk communication to create public understanding of the risks posed by a pandemic, experts and policy makers used another form of communication, advocacy, which is intended not so much to create understanding but to persuade the public to take certain actions. These advocacy efforts were spurred by the events of late 2003 and 2004 when, with SARS (severe acute respiratory syndrome) fresh in everyone’s memory, H5N1 outbreaks emerged in poultry and humans in different parts of Asia. These outbreaks seemed to flu specialists and other public health experts a threat for which governments and the public needed to prepare. The public (and governments, …
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The decisions to stockpile antivirals and influenza vaccines to control avian flu (2005-6) and swine flu (2009) cost large amounts of money.1 2 Both epidemic threats were mostly iatrogenic pandemics of panic, which caused little human suffering, but the global plans to control them were largely a waste of money.1 Was this the consequence of rational risk management in conditions of uncertainty, of fear accompanying any epidemic threat,3 or of close working relationships between disease experts and the drugs industry? Severe acute respiratory syndrome (SARS) in 2003 was an epidemic by an unknown and therefore scary new virus, but we know much more about influenza viruses.2 4 5 The new A/H1N1 swine flu was a far cry from the lethal A/H1N1 pandemic of 1918. There has never been evidence that the recent A/H1N1 virus was anything but mild,6 and it was not reasonable to consider it the first wave of a much more serious second wave. The theory that the 1918 influenza pandemic was caused by a second …
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WHO must act now to restore its credibility, and Europe should legislate
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Neuraminidase inhibitors (NI) are recommended for use against influenza and its complications in inter-pandemic years and during pandemics. To assess the effects of NIs in preventing and treating influenza, its transmission, and its complications in otherwise healthy adults, and to estimate the frequency of adverse effects. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, issue 3) which contains the Acute Respiratory Infections Group's Specialised Register, MEDLINE (1950 to August 2009) and EMBASE (1980 to August 2009). Randomised controlled trials (RCTs) or quasi-randomised placebo-controlled trials of NIs in healthy adults exposed to naturally occurring influenza. Two review authors independently applied inclusion criteria, assessed trial quality, and extracted data. We structured the comparisons into prophylaxis, treatment, and adverse events, with further subdivision by outcome and dose. We identified four prophylaxis, 12 treatment and four post-exposure prophylaxis trials. In prophylaxis compared to placebo, NIs had no effect against influenza-like illnesses (ILI) (risk ratio (RR) ranging from 1.28 for oral oseltamivir 75 mg daily to 0.76 for inhaled zanamivir 10 mg daily). The efficacy of oral oseltamivir against symptomatic influenza was 76% (at 75 mg daily), and 73% (at 150 mg daily). Inhaled zanamivir 10 mg daily performed similarly. Neither NI had a significant effect on asymptomatic influenza. Oseltamivir induced nausea (odds ratio (OR) 1.79, 95% CI 1.10 to 2.93). Oseltamivir for post-exposure prophylaxis had an efficacy of 58% and 84% in two trials for households. Zanamivir performed similarly. The hazard ratios for time to alleviation of symptoms were in favour of the treated group 1.20 (1.06 to 1.35) for oseltamivir and 1.24 (1.13 to 1.36) for zanamivir. Because of the exclusion of a review of mainly unpublished trials of oseltamivir, insufficient evidence remained to reach a conclusion on the prevention of complications requiring antibiotics in influenza cases (RR 0.57, 95% CI 0.23 to 1.37). Analysis of the US FDA and Japan's PMDA regulators' pharmacovigilance dataset, revealed incomplete reporting and description of harms preventing us from reaching firm conclusions on the central nervous system toxicity of neuraminidase inhibitors. Numerous inconsistencies detected in the available evidence, followed by an inability to adequately access the data, has undermined confidence in our previous conclusions for oseltamivir. Independent RCTs to resolve these uncertainties are needed.
Article
Surveillance and studies in a pandemic is a complex topic including four distinct components: (1) early detection and investigation; (2) comprehensive early assessment; (3) monitoring; and (4) rapid investigation of the effectiveness and impact of countermeasures, including monitoring the safety of pharmaceutical countermeasures. In the 2009 pandemic, the prime early detection and investigation took place in the Americas, but Europe needed to undertake the other three components while remaining vigilant to new phenomenon such as the emergence of antiviral resistance and important viral mutation. Laboratory-based surveillance was essential and also integral to epidemiological and clinical surveillance. Early assessment was especially vital because of the many important strategic parameters of the pandemic that could not be anticipated (the 'known unknowns'). Such assessment did not need to be undertaken in every country, and was done by the earliest affected European countries, particularly those with stronger surveillance. This was more successful than requiring countries to forward primary data for central analysis. However, it sometimes proved difficult to get even those analyses from European counties, and information from Southern hemisphere countries and North America proved equally valuable. These analyses informed which public health and clinical measures were most likely to be successful, and were summarized in a European risk assessment that was updated repeatedly. The estimate of the severity of the pandemic by the World Health Organization (WHO), and more detailed description by the European Centre for Disease Prevention and Control in the risk assessment along with revised planning assumptions were essential, as most national European plans envisaged triggering more disruptive interventions in the event of a severe pandemic. Setting up new surveillance systems in the midst of the pandemic and getting information from them was generally less successful. All European countries needed to perform monitoring (Component 3) for the proper management of their own healthcare systems and other services. The information that central authorities might like to have for monitoring was legion, and some countries found it difficult to limit this to what was essential for decisions and key communications. Monitoring should have been tested for feasibility in influenza seasons, but also needed to consider what surveillance systems will change or cease to deliver during a pandemic. International monitoring (reporting upwards to WHO and European authorities) had to be kept simple as many countries found it difficult to provide routine information to international bodies as well as undertaking internal processes. Investigation of the effectiveness of countermeasures (and the safety of pharmaceutical countermeasures) (Component 4) is another process that only needs to be undertaken in some countries. Safety monitoring proved especially important because of concerns over the safety of vaccines and antivirals. It is unlikely that it will become clear whether and which public health measures have been successful during the pandemic itself. Piloting of methods of estimating influenza vaccine effectiveness (part of Component 4) in Europe was underway in 2008. It was concluded that for future pandemics, authorities should plan how they will undertake Components 2-4, resourcing them realistically and devising new ways of sharing analyses.
Article
Knowledge of the age-specific prevalence of immunity from, and incidence of infection with, 2009 pandemic influenza A H1N1 virus is essential for modelling the future burden of disease and the effectiveness of interventions such as vaccination. In this cross-sectional serological survey, we obtained 1403 serum samples taken in 2008 (before the first wave of H1N1 infection) and 1954 serum samples taken in August and September, 2009 (after the first wave of infection) as part of the annual collection for the Health Protection Agency seroepidemiology programme from patients accessing health care in England. Antibody titres were measured by use of haemagglutination inhibition and microneutralisation assays. We calculated the proportion of samples with antibodies to pandemic H1N1 virus in 2008 by age group and compared the proportion of samples with haemagglutination inhibition titre 1:32 or more (deemed a protective response) before the first wave of infection with the proportion after the first wave. In the baseline serum samples from 2008, haemagglutination inhibition and microneutralisation antibody titres increased significantly with age (F test p<0.0001). The proportion of samples with haemagglutination inhibition titre 1:32 or more ranged from 1.8% (three of 171; 95% CI 0.6-5.0) in children aged 0-4 years to 31.3% (52 of 166; 24.8-38.7) in adults aged 80 years or older. In London and the West Midlands, the difference in the proportion of samples with haemagglutination inhibition titre equal to or above 1:32 between baseline and September, 2009, was 21.3% (95% CI 8.8-40.3) for children younger than 5 years of age, 42.0% (26.3-58.2) for 5-14-year-olds, and 20.6% (1.6-42.4) for 15-24-year-olds, with no difference between baseline and September in older age groups. In other regions, only children younger than 15 years showed a significant increase from baseline (6.3%, 1.8-12.9). Around one child in every three was infected with 2009 pandemic H1N1 in the first wave of infection in regions with a high incidence, ten times more than estimated from clinical surveillance. Pre-existing antibody in older age groups protects against infection. Children have an important role in transmission of influenza and would be a key target group for vaccination both for their protection and for the protection of others through herd immunity. National Institute for Health Research Health Technology Assessment Programme.
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2nd Ed Bibliogr. s. 139-141
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WHO has revised its definition of pandemic flu in response to current experience with A/H1N1. Peter Doshi argues that our plans for pandemics need to take into account more than the worst case scenarios
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To determine appropriate influenza pandemic containment and mitigation measures, health authorities need to know the approximate case fatality ratio (CFR) for this new infection. We present four different methods for very provisionally estimating the plausible range of the CFR for symptomatic infection by this pandemic strain in developed countries. All of the methods produce substantially lower values (range 0.06% to 0.0004%) than a previously published estimate for Mexico (0.4%). As these results have many limitations, improved surveillance and serological surveys are needed in both developed and developing countries to produce more accurate estimates.
Article
The Extended Parallel Process Model (EPPM) was developed as a model to assist in the development of effective risk communication messages, specifically messages that elicit adaptive behavioral responses. It has shown to be effective in several settings invoking clearly delineated dangers (e.g., safety belt usage, condom usage).Unfortunately, communicating risk messages is not always so straightforward. One increasing concern in the risk communication field is the controversy over electromagnetic fields (EMFs) and the uncertain hazards they present to individuals. The purpose of this study is to test the EPPM with this unknown risk and to explore which type of risk message may motivate adaptive behavioral responses. In accordance with the EPPM model, 251 participants received either a low- or high-threat risk message and a list of control measures they could use to reduce their exposure to EMFs. Results suggest that the EPPM model can be extended to an unknown risk.
Article
There are important gaps in our current understanding of the influenza virus behavior. In particular, it remains unclear why some inter-pandemic seasons are associated with unusually high mortality impact, sometimes comparable to that of pandemics. Here we compare the epidemiological patterns of the unusually deadly 1951 influenza epidemic (A/H1N1) in England and Wales and Canada with those of surrounding epidemic and pandemic seasons, in terms of overall mortality impact and transmissibility. Based on the statistical and mathematical analysis of vital statistics and morbidity epidemic curves in these two countries, we show that the 1951 epidemic was associated with both higher mortality impact and higher transmissibility than the 1957 and 1968 pandemics. Surprisingly in Liverpool, considered the 'epicenter' of the severe 1951 epidemic, the mortality impact and transmissibility even surpassed the 1918 pandemic.
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I sought to describe trends in historical influenza mortality data in the United States since 1900 and compare pandemic with nonpandemic influenza seasons. I compiled a database of monthly influenza-classed death rates from official US mortality tables for the years 1900 to 2004 (1905-1909 excluded), from which I calculated adjusted influenza season (July 1-June 30) mortality rates. An overall and substantial decline in influenza-classed mortality was observed during the 20th century, from an average seasonal rate of 10.2 deaths per 100 000 population in the 1940s to 0.44 per 100 000 by the 1990s [corrected] . The 1918-1919 pandemic stands out as an exceptional outlier. The 1957-1958 and 1968-1969 influenza pandemic seasons, by contrast, displayed substantial overlap in both degree of mortality and timing compared with nonpandemic seasons. The considerable similarity in mortality seen in pandemic and non-pandemic influenza seasons challenges common beliefs about the severity of pandemic influenza. The historical decline in influenza-classed mortality rates suggests that public health and ecological factors may play a role in influenza mortality risk. Nevertheless, the actual number of influenza-attributable deaths remains in doubt.
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Pandemic and All-Hazards Preparedness Act - Volume 1 Issue 1 - Nellie Bristol, David Marcozzi
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Public health surveillance remains the cornerstone of the detection of health threats requiring public health action. Two articles in this issue of Eurosurveillance refer to the challenges of epidemic intelligence activities in European Union Member States.