Despite huge efforts in the past six years to make the reporting of disease outbreaks fast and automatic, there were significant delays in bringing Mexico's swine flu outbreak to the full attention of international authorities.
News of an outbreak of severe respiratory illness in Mexico burst into public consciousness last Friday, April 24.
That was 18 days after public health authorities there started looking into unusual cases of pneumonia in their country, eight days after Mexican authorities notified the World Health Organization of the growing outbreak and four days after the events came to the full attention of the Centers for Disease Control and Prevention in Atlanta.
Officials involved in pandemic preparedness at the U.S. Department of Health and Human Services, which oversees the CDC, did not learn of the Mexican outbreak until the day the rest of the world did, April 24. They did know, however, that the CDC was investigating six rare cases of swine influenza in California and Texas.
As Mexican health authorities were finding cases of unusual illness, they at least once officially notified the WHO's regional office in Washington, the Pan American Health Organization (PAHO), of a possibly brewing epidemic. People in the WHO's Geneva headquarters also received several urgent warnings from a biosurveillance firm, Veratect, based in Kirkland, Wash.
The delay in making the global health community aware happened despite the adoption in 2005 of international health regulations requiring nations to report to the WHO within 24 hours any disease outbreak that is serious, unusual, at risk of spreading internationally or potentially disruptive of trade. By the time international authorities became fully aware of the outbreak, there were about 800 cases and at least 50 deaths, and the virus was unknowingly being carried into other countries.
What seems apparent is that the world health community's newly rebuilt, well-oiled — but never used — mechanism for warning the world about pandemics may have given nations far less lead time than intended.
"After all this work on flu surveillance and setting up a reporting system and then this — perhaps this isn't the best example of how it's supposed to work," said a highly placed health official in the Obama administration who was not authorized to speak on the record.
After the balky start, however, the WHO's pandemic response system is running well.
'Things seem to be proceeding swimmingly'
Teams of epidemiologists overseen by the WHO (but staffed mostly by Mexican, American and Canadian scientists) are in Mexico investigating the outbreak. The WHO's emergency committee of independent experts has met to evaluate the data. On its advice, Margaret Chan, the WHO's director general, raised the global pandemic alert level from phase 3 to phase 4, and yesterday to phase 5.
"Now things seem to be proceeding swimmingly," said a different high-level health official in the administration, also not authorized to speak by name.
The swine flu epidemic is the first test of the revised International Health Regulations, which were passed by the WHO's 193 member countries in 2005 and took effect June 15, 2007.
The regulations descend from the First International Sanitary Conference, held in Paris in 1851 to fight cholera. In content, they owe much to the severe acute respiratory syndrome (SARS) epidemic of 2003.
That infection, also caused by a virus, emerged in China in November 2002 and spread to 29 countries before being stamped out the following July. In all, there were 8,437 probable cases and 813 deaths, for a "case fatality rate" of 8.6 percent.
In the early, crucial weeks, Chinese authorities played down the number of cases, did not report them promptly to the WHO and moved patients into closed military hospitals to escape discovery. Only when the deception was revealed and the country's health minister ousted was SARS brought under control.
It is under those revised International Health Regulations that countries must report the four categories of diseases, including new subtypes of influenza, to the WHO, as well as any other "public health emergency of international concern."
The full account of the Mexican events will take months to reconstruct. Requests made over the past five days to WHO spokesmen for a rough chronology of events and interviews with experts have not been answered. Similar requests to the CDC have been turned down.
CDC spokesman Tom Skinner said yesterday: "We are working on a very thorough timeline that we will make available . . . when it's ready. . . . Now is simply not the time for us to be sidetracked from what we need to do right now to protect public health."
Mexican health authorities appear to have become concerned about unusual events on April 6, after 400 people sought medical care for pneumonia or a flulike illness in the previous week in La Gloria, in Veracruz state, according to Veratect.
On that day, the company, which provides information to industry, nongovernmental organizations and governments for a fee, sent an alert to its clients titled: "La Gloria: 'Strange' Respiratory Affects 60% of Local Population; Three Pediatric Deaths May be Associated with the Outbreak."
Both the CDC and PAHO have free subscriptions to Veratect's postings. The firm's servers show that an epidemiologist at PAHO looked at the message about the La Gloria events on April 10 and again on April 11, the company's president, Robert Hart, said yesterday.
Veratect sent another alert 10 days later, on April 16, titled "Atypical Pneumonia Cases Reported at Hospital" about severe illnesses in Oaxaca.
One of those cases appears to have been in a 39-year-old woman, whose death from "severe pneumonia with no clear explanation" triggered an investigation at the national level, Mauricio Hernández-Ávila, Mexico's deputy health minister for disease prevention, said in an interview last week.
That same day, Mexican authorities notified PAHO of a worrisome outbreak of atypical pneumonia.
'The fly in the soup'
Asked how PAHO could have learned of Mexico's investigation on April 16 but the WHO not announce the spreading epidemic until April 24, Hernández-Ávila said: "PAHO for some reason did not report. That is the fly in the soup. It looks as if we did something wrong, but we did not."
PAHO spokesman Daniel Epstein confirmed this week that the agency's recipient of disease alerts got a message from Mexican authorities April 16 about an unusual disease outbreak. He said it is impossible that authorities in Geneva did not learn of it at the same time, as the system sends messages through to WHO headquarters automatically.
In any case, Veratect's chief scientist, a physician named James M. Wilson, said he sent its April 16 posting directly to the WHO's Global Outbreak Alert and Response Network because he was so alarmed.
He sent it again April 17, he said yesterday. On April 21, he requested by e-mail that two outbreak specialists at the WHO acknowledge that they had gotten the messages and were aware of the Mexican outbreak. They replied the next day that they were.
Wilson said that in the meantime, on April 20, he called the CDC's emergency operations center in Atlanta and talked with a physician on duty for the global disease detection team. He knew they were investigating swine flu cases in California and Texas.
"I said something like, 'We realize you guys are probably really busy. But the situation in Mexico has gotten to the point where you simply must take a look. And you need to do it now,' " he recalled.
They talked at length, and the CDC physician "indicated that they were not aware" of the problem, Wilson said. The CDC physician later called back and said he "had done some checking and that there was some chatter in the system" about Mexican events, Wilson recalled.
"CDC did not blow us off. After that conversation, they were right on it," he said.