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African Journal of Pig Farming ISSN 2375-0731 Vol. 2 (9), pp. 001-005, September, 2014. Available online at 
www.internationalscholarsjournals.org © International Scholars Journals 

 

Author(s) retain the copyright of this article. 

 

Full Length Research Paper 

 

The cost of double standard risk communication during 
the swine-flu epidemic: Reflections from Norway 

 
John E. Berg 

 
Oslo University College, Faculty of Health Sciences, P. O. Box 4 St. Olavs plass, 0130 Oslo, Norway and 

Blakstad Hosptial Vestre Viken Hospital Trust, 1309 Rud, Norway. E-mail: john@pong.no. Tel: +47 22452000. 
 

Accepted 22 March, 2014 
 
The pandaemia of swine influenza 2009 released a multitude of reactions and actions of public authorities and private 
enterprises. After the first announcement of a probable new epidemic in May 2009 WHO issued a pandaemia warning in 
June 2009. Norwegian health authorities reacted swiftly to the WHO recommendations and Norway became the first 
country opting for buying vaccines for the whole population. The background of the strategy in Norway is described 
using paper media communications and with reference to television broadcasts. The emanating maximizing and 
minimizing strategy followed by the Norwegian health authorities was followed. Tests of the swine flu virus were not 
performed on a scale sufficient to indicate the magnitude of the purported pandaemia. Both strategies were followed 
simultaneously. WHO indicated in June 2010 that hitherto 18 337 people died of the H1N1 influenza virus compared to 
some 500 000 from the common flu each year (Aftenposten 25

th
 July 2010, p. 2). More than $ 14 billion had been spent 

on vaccines and other medical tasks (> $ 750 000 per fatality). In Norway the cost of 9.4 mill. doses of vaccines bought 
was equivalent to $ 3.7 mill. per fatality in 2009. An initial communication of immense risk and purchase of two vaccine 
doses for the total population led to rationing of vaccines when people subsequently wanted them. The cost of this 
decision was far above accepted limits for resource spending on health care. This was followed by communicating a 
small risk of infection for most of the population. Experts exposed differing views on the developing epidemic. Risk 
communication from high decision levels was inadequate. Strategies for handling emerging high risk epidemics must 
be developed and applied in order to reduce fear in the population and huge costs to society. 

 
Key words: Swine influenza, pandaemia, risk communication, cost effectiveness of public health. 

 
INTRODUCTION 

 
Strategies for curbing communicable diseases are well 
developed and exercised, but new infections may not be 
handled in a cost efficient and supporting way for the 
public at risk. However, effective remedies are available 
and logistics may function according to needs in 
developed countries. During the early face of a 
pandaemia relevant information may be hard to get as 
shown in a study by Norgaard and Lazarus (2010). Using 
PubMed as a source they found that only 27.8 records 
out of 44.3 potential records per week were relevant. 
Search strategies are sensitive to inconsistent naming or 
changing nomenclature. If a pandaemia occurs, the risk 
for health care professionals at work, especially in 
hospitals, could increase. Hospital effectiveness may 
thus, be hampered (Damery et al., 2009). In some areas 
of the world access to and delivery of vaccines are 

 
 
 

 
restricted because of socio-economic, logistic or religious 
disparities.  

Persons with influenza like virus diseases have been 
treated with prophylactic vaccines at a voluntary basis 
each year in Norway, that is, the common flu or seasonal 
influenza. The death toll for a population of 4.7 million 
inhabitants has been fluctuating between less than 
hundred and 250 per year. Vaccination of elderly and 
immune-depressed people has been recommended. The 
vaccines have been given free of charge for patients in 
institutions and rest homes. Generally, doctors and 
nurses giving the vaccine did not always get themselves 
vaccinated. Many employers, within healthcare 
organizations and in private companies have offered the 
vaccine to employees, in order to curb sickness absence 
when getting ill. The death toll of the common flu is not 



 
 
 

 

much referred to in media, whereas the new influenza 
with 29 persons certified deceased during 2009 in 
Norway, was intensely focused in media (Table 1).  

Healthcare workers wanting to keep up to date consult 
information sources of differing quality and quantity, from 
scientific journals to public internet information sites. 
There are some evidence that prestigious journals which 
are associated with publications of papers partly funded 
by industry. There is no straightforward relation between 
study quality, concordance, funding and impact in studies 
of influenza vaccines (Jefferson et al., 2009). The director 
general of World Health Oganisation (WHO) dr Chan 
recently dismissed the allegations of influence over 
decisions at WHO from the pharmaceutical industry 
during the first face of the pandaemia (Zaracostas, 2010). 
The British Department of health renegotiated the initial 
deal over swine flu vaccine order when it turned out that 
much less was needed (Mayor, 2010).  

A study of influenza pandemic preparedness has 
indicated low interest among many employers (Watkins et 
al., 2007). Another survey during the swine flu pandaemia 
showed an increased perceived risk (Seale et al., 2010). 
The survey measured perceived risk, seriousness of 
disease, recent behavioural changes and acceptance of 
the vaccine in 627 respondents. When asked how much 
affected you would be 61.4% indicated somewhat 
affected. 57.7% thought the authorities were doing a 
good job and half the respondents thought that getting 
the flu would be out of their control. Washing of hands 
was increased in half the respondents. There was a 
greater willingness of taking the vaccine among women 
compared to men.  

Risk communication is thus difficult. The general public 
may have difficulties understanding standard epidemiolo-
gical jargon. For instance, the difference between relative 
and absolute risks is not understood by many. In an 
online survey of 1290 US adults respondents from larger 
households reported stronger interest in taking 
medications and stick to hygienic measures (Ibuka et al., 
2010). Perceived risk increased over time, but interest in 
pharmaceutical preventive measures and in precau-
tionary hygienic activities decreased over time. A high 
risk in the state did not predict greater interest in 
pharmacological interventions. Five hundred parents 
indicate a willingness to vaccinate against swine-flu if 
they had previously let their children be vaccinated (Flood 
et al., 2010).  

Generally, they would follow the advice of the GP. 
Among parents who did not usually let their children get 
vaccines 44% even stated a perception of the vaccine 
giving influenza. Cowling et al. (2010) sampled 12,965 
Hong Kong residents in a telephone survey between April 
and November 2009 (Cowling et al., 2010). Respondents 
reported low anxiety levels throughout the epidemic. 
Perceived severity was initially high, but declined during 
the epidemic. Knowledge of modes of transmission did 
not increase during the epidemic. Community mitigation 

 
 
 
 

 

activities had little effect. Paradoxical risk perception was 
observed in the urban population of Laos as a result of an 
educational campaign against the avian flu (Barennes et 
al., 2010). After the campaign, the urban population 
considered risk to be decreased and unsafe behaviour 
increased. In the rural areas producing poultry, the 
reaction was opposite.  

Health professionals should be able to evaluate 
epidemiological and biological research. In a web-based 
survey of 947 health–care workers in Australia 59% were 
not convinced that Australia was sufficiently prepared for 
the swine-flu (Tebruegge et al., 2010). A third person 
would refuse to participate in screening suspected 
individuals. Almost half of the group had a private supply 
of vaccines, and only half of the group had a realistic 
estimate of the mortality associated with an influenza 
epidemic. The sheer magnitude of people involved in an 
epidemic is not properly comprehended. Knowledge 
about risk communication is limited or the practical 
application of it is clumsily handled (Moore et al., 2008).  

A pandaemia has to be met by sufficient and effective 
countermeasures. However, a choice must be made 
between preemptive fast reactions on the basis of 
assumptions in the early face of an epidemic, and fact-
based reactions resting on more information. Some would 
argue that a combined approach would be necessary, but 
such a strategy could be bewildering for the public 
(Cornier et al., 2009). The observation of the strategy 
followed by Norwegian authorities and its ensuing cost as 
depicted in newspapers and non-scientific journals was 
the aim of the present commentary. 
 
 

 
MATERIALS AND METHODS 

 
The materials of this study were newspaper and broadcasted 
information of recommendations from the health authorities. The 
newspapers and journals read were both Norwegian and European. 
The strategy of the World Health Organisation (WHO) emanated 
from some of the media references.The communicated 
recommendations and facts were analyzed using a framework of a 
dichotomized strategy of risk minimization and maximization as 
followed by the Norwegian health authorities. A list of the articles 
from newspapers and periodicals used in the work may be obtained 
from the author 
 

 

RESULTS AND OBSERVATIONS 

 

Data on the spread of common flu and swine flu in 
Norway and USA during 2009 are depicted in Table 1. 
The figures are not exact, as no country does test all who 
would have clinical signs of influenza, and post-mortem 
investigations are few and results not always reliable for 
viral diseases. Swine-flu is a new version of influenza 
disease which has affected more young than old people. 
Thus, it is suggested that the data for the case of swine-
flu would be more correct than those for the common flu. 



 
 
 

 
Table 1. Approximate death toll from common influenza and the swine-flu in 2009 in Norway and USA.  

 
 

Norway* 
Norway 

USA# 
USA 

 

 
Per 100,000 population Per 100,000 population  

   
 

Swine-flu 29 0.62 8330 -17160 2.71 – 5.60 
 

Common flu 100 2.13 36000 11.73 
 

 
*) Folkehelsa (State Institute of Public Health), #) Center of disease control and prevention. 

 

 
Table 2. Number of tests for swine flu virus (H1N1) and rhinovirus and percentage of positive tests according to month of testing in Norway.  

 
  H1N1 tests H1N1 % positive tests Rhinovirus tests Rhinovirus % positive tests 

 August 2009 544 3.5 123 39.8 

 September 2009 440 0.7 67 56.7 

 October 2009 521 25.3 92 46.7 

 November 2009 1267 39.8 114 32.5 
 
 

 
Table 3. Two strategies for risk communication to the population during an epidemic.  

 
Strategy 1: Minimize risk perception and calm the 
population  

 
 
Strategy 2: Maximize risk perception and keep the 
population alerted  

Buy vaccines at same level as for the common flu 
 

 

Face mask use discouraged 

 
Keep schools open 

 
Vaccination according to narrowly defined risk groups 

 

Doubts about effectiveness of vaccination among 

virologists The economic impact of the swine flu is small 

  
Front edge strategy: Order and buy vaccines for the whole 
population (for vaccination twice) 

 

Face mask use enhanced through free delivery 

 

Close schools and kindergartens 

 
Open vaccination of politicians and senior health officials first 

 
Dissuade hugging in schools  

 

 

 

Some 900 000 Norwegians were allegedly infected. 2.2 
million inhabitants got the vaccine. 1300 persons were 
remitted to hospital and 200 received intensive care. 
Laboratory testing was initially recommended, but 
laboratory capacity was not sufficient and the authorities 
soon recommended not testing of persons without 
serious signs of disease. General practitioners sent the 
samples to the laboratory. The percentage of positive 
tests among those tested is shown in Table 2. 

 

How did the Norwegian health authorities meet this 
challenge? 
 
Over time, the health authorities and health care 
politicians gave disparate and changing information, both 
according to scope and content. Two different paradigms 
of information can be summarized as in Table 3: 
 

i. Pandaemia with less health effects than the seasonal 

 
 

 

influenza will develop, strategy 1 in Table 3. This point, if 
true, would not generate a need for other actions than in 
a normal seasonal influenza year. No intervention would 
be recommended in schools and hospitals, and 
recommendations for vaccination would be the usual 
weak and immunosuppressed groups of patients. But 
early observations indicated a substantial mortality rate in 
younger age groups than for the well known seasonal 
influenza. One might suppose that, the health authorities 
would be afraid of being condemned as reckless if they 
maintained the advice of strategy 1, especially if media 
wrote extensively on the first child dying in the early face 
of the epidemic. This was the case in some of the 
newspaper articles listed below. The Norwegian health 
authorities appeared on TV and radio informing the public 
on both strategies depicted in Table 3, often within the 
same five minute broadcast.  
ii. Pandaemia with serious health effects will develop 
strategy 2 in Table 3. According to this strategy there is a 



 
 
 

 

need for harsh measures and immediate action. This was 
demonstrated in Norway by a very rapid decision. The 
government bought 9.4 million doses of the vaccine 
under development, that is, enough to vaccinate the 
whole population twice. The price was 69 NOK = $ 11 per 
dose, that is, $ 108 mill. Early indications from WHO 
suspected a need for two vaccinations in every person 
under risk. As far as we know no other country did order 
so many vaccines.  

Some members of the medical profession were 
interviewed in the media exposing recommendation with 
unclear epidemiological meaning. Like stating that 
women should not get pregnant during the epidemic, 
although a risk in early pregnancy was not documented, 
and the uncertainty introduced by such a statement would 
make life intolerable for some. Especially if inadvertently 
getting pregnant during the epidemic. Information 
regarding putative actions in schools, rest homes and 
kindergartens had a double standard. One day no actions 
were advocated, the next day closing of schools was 
recommended. Vaccination of health workers was initially 
done only in emergency medical units, not in emergency 
psychiatric units, not taking into account that persons with 
serious psychiatric illnesses would constitute a greater 
risk of getting infected or spreading the infection to 
others. By maximizing risk perception before enough 
vaccines were available, large queues and aggressive 
incidents occurred at general practitioner offices. 
 
 
 

Conclusions 

 

The consequences of uncertain and dispersed advice 
from health authorities and its reception in media were: 

 

1. Huge costs of ordering swine flu vaccine at a time 
when it was not even put into production in order to 
secure delivery before other countries came up with a 
decision. WHO has indicated that hitherto 18 337 people 
died of the H1N1 influenza virus compared to some 500  
0 who die of the common flu each year (Aftenposten 
25th July 2010, p. 2). More than $ 14 billion has been 
spent in the World on vaccines and other medical tasks 
(> $ 750 000 per fatality). The Norwegian cost of 9.4 mill. 
vaccine doses in 2009 is equivalent to $ 3.7 mill per 
fatality that year.  
2. Untoward buying of two vaccines per person at risk. 
This turned out to be unnecessary. The cost could thus 
have been the half of the above mentioned.  
3. Creating havoc at vaccine offices, general practice 
offices and some hospitals as people rushed to get a 
rationed good.  
4. Vaccination of health workers in a sequence ignoring 
the risk of acutely ill persons with mental disorders. Only 
health workers caring for acutely somatically ill persons 
were initially vaccinated. No compulsory vaccination of 
any group was instituted. Top health authorities and 

 
 
 
 

 

members of the government got priority vaccinations.  
5. Trust in health authorities reduced. Both the general 
public and medical and other experts had difficulties 
following and understanding advice given.  
6. The death toll of common flu is according to data from 
2009 about four times higher per 100,000 inhabitants 
than for the swine flu (Table 1).  
7. The media coverage contributed to two strategy 
initiatives focusing on the few severe illness episodes and 
the organization of distributing a rationed good. 

 

Risk communication must be based on knowledge and 
given to the public in an understandable and coherent 
way. Standard explanations of risk models should be 
available to all media as soon as an epidemic or other 
catastrophes occur, and they should be produced and 
ready in the relevant public relation offices of the health 
authorities. It would be difficult and probably unreliable 
what journalists themselves could produce at short 
notice. If media could run such pre-made broadcasts 
instead of repeating stories on extreme cases, both the 
public and health authorities would be able to absorb the 
different messages of Table 3 in a meaningful manner. 
Some newspaper articles (Vårt Land 17.11.09) indicated 
that the vaccine producing companies had a very strong 
negotiating power at the start of the epidemic, maybe 
contributing to the huge costs incurred. 
 

 

ADDENDUM 
 

After the main work with this paper was done reports 
have been published showing uncertainty regarding the 
decision on buying the vaccines (Aftenposten 23.10.10). 
Three levels of the health authorities disagree on who 
was responsible for the decision. 
 

 
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