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CLINICAL REVIEW: Douglas Fleming Influenza pandemics and avian flu BMJ 2005; 331: 1066-1069 [Full text]

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Rapid Responses published:

Correction

Douglas M Fleming   (4 November 2005)

Broadening the response

Jim A Paris   (7 November 2005)

Flu vaccines and hypersensitivity to eggs

Jean-Francois Gehanno, Laure Couderc   (7 November 2005)

Fleming on Influenza

Dr Ian R Thompson   (7 November 2005)

Out of hours organisations plans

john sharvill   (7 November 2005)

Flu Vaccines Grown on Hen's Eggs - Invitation to Bird Flu Through the Back Door?

Di Newman   (26 November 2005)

Flu vaccination and pancreatitis

Nitin Mukerji, Trivikram Garud, Reem Hasan, Fintan G. Bergin   (17 February 2006)

Correction 4 November 2005
Douglas M Fleming, Unit Director Birmingham Research Unit RCGP Birmingham B17,9DB Send response to journal: Re: Correction	An error was printed in Example4. Pregnacy is not a contra-indication for flu vaccination. The corrected version should read Learning point: Example 4 A 66 year old man with a history of stroke has read that the flu vaccine can cause strange neurological illnesses. What should you say to him? Flu vaccine does not cause strokes. He may have read about Guillain- Barré syndrome, but this condition is extremely rare, perhaps occurring at a rate of about one additional case per million people vaccinated. A history of Guillain-Barré syndrome is no longer considered to be a contraindication for vaccination. Pregnancy is not a contraindication for vaccination. True hypersensitivity to eggs is a contraindication because flu vaccines are developed from virus material grown on hens' eggs. Competing interests: None declared
Broadening the response 7 November 2005
Jim A Paris, retired public health consultant and former GP PR3 2NB Send response to journal: Re: Broadening the response	This paper is very timely. There must be many retired doctors and nurses who would be happy to offer their services should the need arise. Before considering returning to practice, even for a short time, I would want to update my knowledge and skills. I think Primary Care and Hospital Trusts should consider ways of enabling each health care proviser to have a number of retired or otherwise employed health care professionals in ongoing training and appropriately registered to be able to be called up at short notice to assist in the event of an epidemic or other emergency where additional health care workers are required for significant periods. This could be organised by Stategic Health Authority area in similar ways to the Territorial Army. Yous sincerely Jim Paris Competing interests: Retired doctor
Flu vaccines and hypersensitivity to eggs 7 November 2005
Jean-Francois Gehanno, Senior Lecturer Department of Occupational Medicine, Rouen University Hospital, 76031 Rouen, France, Laure Couderc Send response to journal: Re: Flu vaccines and hypersensitivity to eggs	Dear sir, Douglas Fleming states that true hypersensitivity to eggs is a contraindication because flu vaccines are developed from virus material grown on hens' eggs. Some studies supports the relatively safe administration of influenza vaccine to individuals with egg allergy, providing this vaccination is performed using specific protocols and under the supervision of experienced physicians (1,2). Such a protocol including incremental dosing of influenza vaccine has been presented by Zeiger in 2002 (3). In those times of possible influenza pandemics, the risk-benefit ratio of the vaccine could be re-considered in patients with egg allergy, especially for those at high risk for complication of influenza or for healthcare workers. It would also be useful for companies that manufacture these vaccines to provide information concerning the egg protein content of their vaccine. 1. James JM, Zeiger RS, Lester MR, Fasano MB, Gern JE, Mansfield LE, Schwartz HJ, Sampson HA, Windom HH, Machtinger SB, Lensing S. Safe administration of influenza vaccine to patients with egg allergy. J Pediatr 1998;133:624-8. 2. Murphy KR, Strunk RC. Safe administration of influenza vaccine in asthmatic children hypersensitive to egg proteins. J Pediatr 1985;106:931- 3. 3. Zeiger RS. Current issues with influenza vaccination in egg allergy. J Allergy Clin Immunol 2002;110:834-40. Competing interests: None declared
Fleming on Influenza 7 November 2005
Dr Ian R Thompson, Locum SpR King's College Hospital SE5 9RS Send response to journal: Re: Fleming on Influenza	Editor, I, like every colleague I know, am following the news on Avian influenza with interest. Whether an influenza pandemic follows sooner or later, we all accept that a pandemic is due. I have not seen anything in the news or medical media of the type of advice given by the American Center for Disease Control (on http://www.cdc.gov/flu) regarding, for example, handwashing to prevent epidemic - as well as pandemic - flu. Although not entirely sure of the evidence base for the assertion that handwashing reduces the transmission of flu, it does make intuitive sense, droplet spread not being restricted to the inhalation of someone else's sneezes as the term tacitly implies. The evidence base cannot be that much worse than for the effectiveness of Tamiflu! Could we have some simple advice for medics and non-medics regarding simple measures people may take? Might that reduce some of the anxiety being felt in certain quarters? Yours faithfully, Dr Ian Thompson MRCP Locum SpR King's College Hospital, London SE5 Competing interests: None declared
Out of hours organisations plans 7 November 2005
john sharvill, gp ct14 7au Send response to journal: Re: Out of hours organisations plans	The responsibility for out of hours calls in the UK in most areas been given to independent provider organisations so the article will hopefuly be read by their managment teams as well as clinicians. Competing interests: None declared
Flu Vaccines Grown on Hen's Eggs - Invitation to Bird Flu Through the Back Door? 26 November 2005
Di Newman, Concerned with Health & Environmental issues Cambridgeshire Send response to journal: Re: Flu Vaccines Grown on Hen's Eggs - Invitation to Bird Flu Through the Back Door?	Although no rocket scientist, I should have thought developing vaccines in hen's eggs was a dodgy practice these days and something to be more then just concerned about, in light of the Government's somewhat frenzied attempts at educating the the mases on how the Bird Flu will finish us all off! Yet, we read about a common practice of developing millions of vaccines by a process that would appear to be an ideal platform for the Bird Flu virus to potentially jump species. Clearly this practice is wide spread, seemingly carried out by those who appear unaware of any such danger in their creating a hotline for Bird Flu strain to enter the human chain and easily so, with along whatever vaccine / s they are developing in the hen's eggs. Does this practice not raise concern of the potential dangers of inadvertantly inviting the Bird Flu to creep through the back door? Afterall, is that not what the media keep banging on to us about e.g. the opportunity for it to mutate! Is this practice not an invitation to the Bird Flu virus to mutate, at its convenience and leisure! We, members of the public, would not have privy, for a variety of unknown reasons, to the information regarding where these "hen's eggs" may or may not come from e.g. which country / area they are breed, conditions they are fed or raised in, or from where imported and suchlike. Therefore, we would remain totally unaware to the fact that we could inadvertantly be risking ourselves and that of family members to this eventual possiblity of being infected with a form of "Birds Flu" that could well jumped species through this vaccine-practice? Developing vaccines in hen's eggs is surely risking - if not inviting the Bird Flu "through the back door" and this approach in vaccine development under the present global fears and panic, beggars belief and should be immediately banned. Would some kind Professor - rocket scientist, or not, please shed some light, sense and reason on this dangerous practice before it is too late and we, the public, are paying the price with our lives, yet again, in the name of profit and drug companies, alike. Competing interests: member of the public
Flu vaccination and pancreatitis 17 February 2006
Nitin Mukerji, Basic Surgical Trainee Royal Victoria Infirmary, Newcastle-upon-Tyne, NE1 4LP, Trivikram Garud, Reem Hasan, Fintan G. Bergin Send response to journal: Re: Flu vaccination and pancreatitis	Influenza vaccination is now routinely offered in the UK for all aged 65 years and over and all aged over 6 months in the following groups’ viz. chronic respiratory disease, including asthma, chronic heart disease, chronic renal disease, chronic liver disease, diabetes, immunosuppression, those living in long-stay residential and nursing homes or other long-stay facilities and those who are the main carer for an elderly or disabled person1. It is generally well tolerated and recognised side effects include soreness at the vaccination site, fever, malaise, myalgia, and arthralgia. Immediate allergic reactions such as urticaria, angio-oedema, bronchospasm, and anaphylaxis are rare. We encountered an interesting case of a 51- year- old lady, who was admitted to the surgical wards in October 2005 with a diagnosis of acute pancreatitis without a definitive cause, which we would like to share. The history and a serum amylase of 1427 u/l confirmed the diagnosis. She was not known to have gallstones and denied any alcohol intake. Interestingly she had been admitted around the same time in 2004 with a similar diagnosis. She had a history of NIDDM and hypertension and her medications at the time of the current admission included metformin, fenofibrate, amlodipine and premarin. Investigations revealed a mildly high triglyceride level (2.6mmol/L) and no other common causes of pancreatitis were identified. The only consistent factor in the history seemed to be a ‘flu-jab’ approximately 10-15 days prior to each of the hospital admissions. On obtaining further information from the patient’s general practitioner, we found that she had a flu vaccination in 2003 uneventfully but both the flu vaccinations in 2004 and 2005 were followed by an episode of pancreatitis. A literature review investigating an association was not very informative. We found just one report of pancreatitis and cholestatic hepatitis and pancreatitis associated with influenza virus vaccine2. We did find documented evidence of acute pancreatitis associated with measles, mumps and rubella (MMR) vaccination3,4, varicella vaccination5, hepatitis A vaccination6 and typhoid and cholera vaccination7. Amongst the recognised adverse effects of influenza vaccination were neuropathy8, isolated hypoglossal nerve paralysis9, Guillain-Barre syndrome10, relapsing encephalomyelitis11 and optic atrophy12. Since the investigations did not reveal any significant biochemical or radiological abnormalities that could be definitively identified as the cause for the pancreatitis we believe considering the vaccination as associated with the pancreatitis may be a possibility. That the probable mechanism of causation could be immunologic in nature might explain why the patient did not have the pancreatitis on the first occasion she had the jab. Influenza vaccine is prepared each year using virus strains (which are inactivated) recommended by the World Health Organization. Two types of influenza vaccine are currently available in the UK; split virus and surface antigen vaccine1. These are equally effective and have a similar adverse reaction rate. A live attenuated influenza vaccine is also produced, but is not licensed in the UK. Influenza immunization provides protection against strains related to those in the vaccine for about 1 year and should be repeated annually. Given the recent concerns about bird flu and an increase in the vaccination rate this rare association might be worth keeping in mind. REFERENCES: 1. Department of Health. The Influenza Immunisation Programme. London: DH, 2005. (PL/CMO/2005/2). 2. Influenza virus vaccine: Pancreatitis and cholestatic hepatitis: Case report. Reactions 1993;1:9. http://www.ingentaconnect.com/content/adis/rea/1993/00000001/00000480/art00026 3. Adler-J-B, Mazzotta-S-A, Barkin-J-S. Pancreatitis caused by measles, mumps, and rubella vaccine. Pancreas 1991;6:489-490. 4. Feldman-G, Zer-M. Infantile acute pancreatitis after mumps vaccination simulating an acute abdomen. Pediatr-Surg-Int 2000;16:488-89. 5. Chan-P-W, Goh-A-Y. Life threatening pancreatitis following varicella vaccination: cause, association or co-incidence? Med-J-Malaysia 2000;55:527-8. 6. Haviv-Y-S, Sharkia-M, Galun-E, Safadi-R. Pancreatitis following hepatitis A vaccination. Eur-J-Med-Res 2000;5:229-230. 7. Gatt-D-T. Pancreatitis following monovalent typhoid and cholera vaccinations. Br-J-Clin-Pract 1986;40:300-301. 8. Furlow TW Jr. Neuropathy after influenza vaccination. Lancet. 1977;29:253-4. 9. Felix JK, Schwartz RH, Myers GJ. Isolated hypoglossal nerve paralysis following influenza vaccination. Am J Dis Child. 1976;130:82-3. 10. Morris JA, Young BG. Guillain-Barre syndrome. Lancet. 1978;16:636. 11. Yahr MD, Lobo-Antunes J. Relapsing encephalomyelitis following the use of influenza vaccine. Arch Neurol. 1972;27:182-3. 12. Macoul KL. Bilateral optic nerve atrophy and blindness following swine influenza vaccination. Ann Ophthalmol. 1982;14:398-9. Competing interests: None declared Editorial note The patient whose case is described has given her signed informed consent to publication.