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EDITOR'S CHOICE: Tony Delamothe FAFfing about BMJ 2007; 334: 0 [Full text]

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Rapid Responses published:

Is your guess like mine?

Hilary Butler   (29 June 2007)

Mo Delamothe

Elona Craggs   (29 June 2007)

Re: Mo Delamothe

Tony Delamothe   (29 June 2007)

FAFfing about: BFF on bird flu

Greg Dworkin, MD   (29 June 2007)

Sir, do you have information that no one else has?

Nancy C. Owens   (29 June 2007)

response to Tony Delamothe's questions

Greg Dworkin, MD   (29 June 2007)

Yes, just FAFfing about.

Helen Neish   (30 June 2007)

More response: Egypt, via WHO

Greg Dworkin, MD   (30 June 2007)

Who cares about column inches?

Susan Chu   (30 June 2007)

FAFfing about

Sheila A Edgar   (30 June 2007)

Hope is not a plan. A plan is not preparedness.

Joel H. Jensen   (30 June 2007)

Questions to Greg Dworkin.

Hilary Butler   (30 June 2007)

False assumptions about the speed and limits of evolving viruses

V. Switzer   (30 June 2007)

Re Hilary Butler's questions

Greg Dworkin, MD   (30 June 2007)

Pandemic Insurance

Peter Dunnill   (30 June 2007)

correction

Greg Dworkin, MD   (30 June 2007)

Re: False assumptions about the speed and limits of evolving viruses

Edna Mode   (30 June 2007)

AIDS was once jsut 191 victums

Kobie A Marou   (1 July 2007)

On the nature of concerned peoples

Ellen Rice   (1 July 2007)

Evaluating Pandemic Risk

Susan Chu   (2 July 2007)

A long fast?

Jane Lawrence   (2 July 2007)

Has the BMJ Gone a Bit Too Far?

Jay Ilangaratne   (2 July 2007)

AIDS is not such a big problem

Dave Null   (2 July 2007)

FAFfing about

Dr Frank Wells   (2 July 2007)

Envisioning the worst

David S. Fedson   (3 July 2007)

Promotional healthscares

John Stone   (4 July 2007)

re John Stone's comment

Greg Dworkin, MD   (6 July 2007)

Re: Promotional healthscares

Susan Chu   (8 July 2007)

Re: Promotional healthscares

V. Switzer   (8 July 2007)

Re: Re: Promotional healthscares

John Stone   (9 July 2007)

Re vaccines, predictions, etc

Greg Dworkin, MD   (11 July 2007)

Re: Re vaccines, predictions, etc

John Stone   (13 July 2007)

The State of FAF (Fear of Avian Flu)

Luc G. Bonneux, 2502 AR Den Haag   (13 July 2007)

Is your guess like mine? 29 June 2007
Hilary Butler, freelance journalist. Home, Tuakau, 2121, New Zealand. Send response to journal: Re: Is your guess like mine?	Congratulations Mr Delamothe, on some commonsense. However, a betting man, might be prepared, with a bit of analysis to take on this statement: >>>H5N1 had been groomed for stardom, but now it can be any influenza strain that becomes pandemic, further details unknown.<<< Quick analysis of the facts shows us that; while H5N1 first hit the WHO books in 1959 (http://www.who.int/csr/don/2004_03_02/en/) it has presumably been around for a fair few more years than that. What evidence does history show, that H5 is EVER a pandemic human pathogen, or that it can mutate to transmit human to human with efficacy? Zilch. So what were the strains of the flu epidemics which you might call pandemics, and in what years did they occur? We see this: (check it out yourself. This isn't a guessing game.) 1889 ------- H2 *************** 1900 ------- H3 *************** 1918 ------- H1 *************** 1957 ------- H2 *************** 1968 ------- H3 *************** 1986 sort of pandemic ------- H1. *************** The time gap between the two H2 epidemics is 68 years. The time gap between the two H3 epidemics is 68 years. The time gap between the two h1 epidemics is 68 years. Amazing. The haemagluttins obligingly fall in a pattern which goes: 2,3,1; 2,3,1. So if we assume that "nature" has designated a new geneation will pass nearabouts to the biblical 70 years (68 years) before a clean generation gets a pandemic "hit"; and if a pandemic of another type will follow that same pattern, wouldn't logic dicate that the next pandemic might be H2, and it might be 68 years after 1957 which would be ... what? 2025? So do we have a bookmaker prepared to take odds on that? I suspect this calculation has more merit than the current faffing around, but then, what would we mere mortals know? Sincerely, Hilary Butler. Competing interests: None declared
Mo Delamothe 29 June 2007
Elona Craggs, mother My home LS24 9JE Send response to journal: Re: Mo Delamothe	Did you actually do any research on the latest human cases in Egypt and Indonesia before writing this article? Are you aware that the WHO has admitted a human to human cluster in Indonesia a couple of months ago and that presently there is what looks like a human cluster in Egypt? The USA has just announced it will give 24 million to Egypt to help it combat H5N1 in birds and in humans. Massive efforts are being made in several countries to build vaccine plants. Indonesia's health minister, addressing the WHO said that they were "fighting a war" against human H5N1 and that she hoped to start vaccinating people in July this year as in Indonesia the fatality rate is 79%. It mainly affects children and can kill in a matter of days - this is in a modern hospital with access to drugs, medical care and ventilators. How many British tourists visit Egypt every year and could return with a souvenir that they really do not want. The WHO has stated that with today's speed of international travel - the virus could spread across the world in days - not weeks. I would love to think that you were cognisant of some reassuring information that would make WHO and the CDC as well as the UN wrong in their belief that this is a clear danger to the world. If you would like to publish a follow up article based on science and recent actual information rather than a "sulk" that your area of interest is not forefront, then I would love to read it. Competing interests: I have been reading about H5N1 since January 2007 especially the HHS blog in the USA.
Re: Mo Delamothe 29 June 2007
Tony Delamothe, deputy editor, BMJ BMA House, London Send response to journal: Re: Re: Mo Delamothe	I am grateful to Elona Craggs for bringing the HHS blog to my attention. Its Pandemic Flu Leadership Blog is certainly a treasure trove of information.[1] I haven't had time to digest it all, but the first thing that caught my eye was that the blog was compiled by two employees of the Ogilvy Public Relations Worldwide’s 360 Degree Digital Influence team.* If this was pro bono work, why did Ogilvy think this was a good use of their resources, given other competing calls on their philanthropy? As regards the status of the pandemic, WHO's website says we're in phase 3: "a new influenza virus subtype is causing disease in humans, but is not yet spreading efficiently and sustainably among humans." [2].I couldn't find that WHO had "admitted a human to human cluster in Indonesia a couple of months ago." There was a widely publicised family cluster in May 2006, but I didn't know that it had been confidently ascribed to human to human spread. Do you have the reference to the more recent episode you mention and the suspicious Egyptian outbreak? [1]http://blog.pandemicflu.gov/ [2 http://www.who.int/csr/disease/avian_influenza/phase/en/index.html Addendum: * From http://www.ogilvy.co.uk/fellows/default.asp "360 is...about reaching people at poignant and meaningful moments during their day. 360 degree branding basically places the consumer in the middle of all the media they are exposed to - and then uses those that can best deliver a particular message in the most relevant way to build a campaign. In a 360 campaign all the chosen media say the same thing. This means that whenever someone comes into contact with a brand, be it on the back of a bus or online, they will always get the same message." Competing interests: None declared
FAFfing about: BFF on bird flu 29 June 2007
Greg Dworkin, MD, pediatric pulmonologist Danbury, CT 06810 Send response to journal: Re: FAFfing about: BFF on bird flu	Thank you for your interesting opinion, which is, alas, both wrong-headed and wrong-hearted. It is wrong-headed because the amount of preparation for a pandemic (inevitable whichever virus comes) is so extensive that only doing this in advance, and with everyone (including the public) involved, makes sense. See Commentary on Community Mitigation of Pandemic Influenza The [U.S.] Department of Health and Human Services’ planning assumptions for an unmitigated and severe (1918-like) pandemic include 9.9 million hospitalizations in the US with 1.5 million patients requiring intensive care, figures which are several times the available capacity of the healthcare system. In fact, the US healthcare system would be seriously challenged by even a mild pandemic. For this reason, public health interventions which might reduce this disease burden have attracted much interest.[bolded mine] and see HHS hears community leaders' ideas on pandemic readiness for a better approach that involves the public. Rather than less public planning, more public planning and transparency will improve outcomes, involve citizens, and allow greater trust in authorities' efforts. It is wrong-hearted because vulnerable populations need to be assured they are not left behind in planning. BMJ should follow Lancet's lead and give this the attention a serious topic like pandemic mitigation deserves. And, in fact, preparing for a pandemic will bolster the public health infrastructure to handle whatever comes, usually more unexpected than planners like to admit. Thanks for taking up the topic. Best friends forever (BFF) on bird flu? Competing interests: Editor, Flu Wiki, non-commercial volunteer website
Sir, do you have information that no one else has? 29 June 2007
Nancy C. Owens, Technical Rep.--Industrial Chemicals 37933 Send response to journal: Re: Sir, do you have information that no one else has?	I read your article titled "FAFfing About" and am just dumbfounded as to where you are obtaining your facts in order to write something like this. Your oppinions certainly do differ from WHO, the CDC, the UN and many, many scientist and doctors. I suggest you re-examine the facts about the H5N1 virus and that you interview the "experts" in this field before "beating up" the voices of us who follow the events taking place on a day to day basis. We are not using "scare tatics" on anyone. We are only trying to get the message out to anyone who wants to know what is going on and who wants to make preparations to protect themselves and their families when a pandemic occurs. It is not a matter of "if" but a matter of "when"! It may not be the H5N1 virus that causes a pandemic but history is proof that some kind of disease will. I suggest you spend more time preparing yourself and less time writing articles berating informed and dedicated people. Competing interests: None declared
response to Tony Delamothe's questions 29 June 2007
Greg Dworkin, MD, Chief, pediatric pulmonology, Danbury Hospital Danbury CT 06810 Send response to journal: Re: response to Tony Delamothe's questions	I was an unpaid non-government volunteer to the HHS blogging effort (posts are here) and participated in their Leadership Summit on 13 June, 2007. I have no idea what Ogilvy PR's arrangements were, but they do have a 3 year contract with HHS to help the department with communications projects. I cannot speak for them. I also volunteer for my local panflu and all hazard task forces (school, city, hospital). I do so because of the response in my previous post - this is a real threat and takes time to respond to properly, and the planning aids us all in meeting other potential hazards. As to clusters and H2H transmission and WHO this is from June 2006: H5N1 mutation showed human transmission in Indonesia Jun 23, 2006 (CIDRAP News) – The recent family cluster of H5N1 avian influenza cases in Indonesia marks the first time laboratory tests confirmed human-to-human transmission, the World Health Organization (WHO) told reporters today. According to news reports, WHO officials said the virus mutated slightly when it infected a 10-year-old boy, and he passed the altered virus on to his father. Detection of the altered strain in both the boy and his father was evidence of direct transmission. The mutation did not make the virus more transmissible, and the boy's father, who died of the illness, did not pass it on to anyone else, WHO officials were quoted as saying. "We've never really had a fingerprint to confirm human-to-human transmission like we had here," said WHO spokesman Dick Thompson, as reported by Agence France-Presse (AFP) today. This news report discusses the possibility of H2H in Sept 2006. Previous WHO statements do acknowledge the likelyhood of occasional and rare H2H cases in Thailand and Vietnam in years prior. Competing interests: Editor, Flu Wiki, non-commercial volunteer website
Yes, just FAFfing about. 30 June 2007
Helen Neish, Retired N/A Send response to journal: Re: Yes, just FAFfing about.	Is the AIDS budget a little lower this year because somebody thinks that an illness that could kill more in 20 weeks than have died in 20 years of AIDS needs some money spent on it? An illness, moreover, that would particularly target those AIDS victims? It’s a pity, but there is only so much money to go around. ‘But why should we be any more worried in 2007 than in 1997 or 2017?’ Well, maybe we should have been worried before now and maybe by 2017 we’ll be wishing more people, including you good self had worried a little more? ‘Couldn't those responsible for planning for the next pandemic do their planning less publicly’. I know, I know, those people desperately trying to drum up awareness amongst the poor bird farmers of Indonesia and Egypt are such a boor. They should shut up about it and let those people die in ignorance, it’s not that many of them and they’re mostly kids. OK, those people die of severe ARDS but that’s no biggie, is it? And then there’s the huge cost from bird deaths, both in money and reduction in food production. Never mind, I’m sure the farmers are all compensated... by somebody. And I’m sure that an increased incidence of bird to human contact won’t increase the chances of mutation. I mean, it’s not as if it’s mutating rapidly... oh my mistake, it is. ‘And put the frighteners on the rest of us at the appropriate time?’ When would that be? When there is a pandemic sweeping the world? When the first UK victims are the lucky people who get those respirators that are in short supply? When you get sick? When the first children die? It’s been done before, but for your own education, perhaps you could work out how many UK children would die in a pandemic. Then compare the figure with a normal annual death rate. Remember that kids have a higher attack rate (AR) because they’re ‘super spreaders’. The answer is shocking. The cost of a 1918 style pandemic (nobody is prepared to consider anything worse) is estimated at $800 billion. Isn’t it worth a little diligence now, to try and mitigate that? Nah, I’m sure we’re just FAFfing about. Competing interests: None declared
More response: Egypt, via WHO 30 June 2007
Greg Dworkin, MD, pediatric pulmonologist Danbury, CT 06810 Send response to journal: Re: More response: Egypt, via WHO	This is a suspicious cluster: Avian influenza - situation in Egypt - update 13 2 April 2007 The Egyptian Ministry of Health and Population has announced three new human cases of avian influenza A(H5N1) virus infection. The cases have been confirmed by the Egyptian Central Public Health Laboratory and by the US Naval Medical Research Unit No.3 (NAMRU-3). The first case, a 4-year-old boy from Qena Governorate, is the brother of the 6-year-old girl whose infection was reported on 28 March. He developed symptoms on 26 March and was admitted to hospital on 29 March. More clusters can be seen here in Dr. Fukada's WHO slides from June, 2007. Slide 13 has a nice cluster graph, with increasing number of suspicious clusters. While H2H is unproven, slide 8 mentions "limited human-to-human transmission cannot be ruled out" whereas sustained H2H has not occurred. The body of evidence suggests that H5N1 continues to be a problem that deserves serious surveillance, and the precautionary principle strongly suggests that pandemic preparedness continue apace. Competing interests: Editor, Flu Wiki, non-commercial volunteer website
Who cares about column inches? 30 June 2007
Susan Chu, Editor, Flu Wiki Oxfordshire, OX7 4HT, UK Send response to journal: Re: Who cares about column inches?	Sir, I read with astonishment and dismay your latest article published as 'editor's choice' in the BMJ. Your comment But others were relatively new: the terminological mutation from "avian flu" to "pandemic flu," in recognition of H5N1's failure to mutate genetically. appears to suggest a particularly novel origin of the term "pandemic flu", possibly as a figment of some collective imagination or, worse, a cynical attempt to compete for column inches. May I suggest with regards to the last consideration that, contrary to your unusual sense of priorities, this issue is of little consequence to the vast majority of BMJ readers, the men and women of science who are more interested in receiving accurate information and debating issues on scientific merit. More importantly, let me point out that since March 2005, with the declaration of pandemic alert phase 3, the WHO has placed the world on notice for an increased risk of a possible pandemic from an avian influenza virus that has repeatedly infected humans, ie neither the risk of a pandemic from H5N1, nor the necessity to prepare for it, are based on anything but the most rigorously researched and reviewed scientific information. Whilst not suggesting that AIDS is anything but a serious challenge and a tragedy, I am disturbed that you appear to consider mitigating the consequences of different catastrophic diseases as a zero sum game, that there is a need to justify one's preference for paying attention to one risk over another. Whilst I do not subscribe to such a worldview, perhaps I can assist you in yours by picking up your gauntlet and examining a few of the reasons why pandemic influenza, particularly one caused by H5N1, needs to be approached with as much if not more seriousness and urgency than HIV/AIDS. HIV/AIDS infected 60 million people over 20+ years. A pandemic caused by any novel flu virus, at the lowest estimate, is going to infect and sicken 25% of the world's population ie 1.7 billion, within 6 months. The current H5N1 virus has an overall case fatality rate CFR of 60%. With regards to whether such a high CFR will be retained in a pandemic, a recent WHO working group report states that Should the virus improve its transmissibility by acquiring, through a reassortment event, internal human genes, then the lethality of the virus would most likely be reduced. However, should the virus improve its transmissibility through adaptation as a wholly avian virus, then the present high lethality could be maintained during a pandemic. Even taking the optimistic view, this virus has to become 30 times (not 30%) milder before it matches the lethality of the 1918 pandemic (ie CFR = 2%), arguably the worst single epidemic disease in the shortest timeframe in human history. At 2% CFR for 1.7 billions sick, the death toll will be 34 million over 6 months. In comparison, tragic as it is, HIV/AIDS has 'only' killed some 25 million people in 20 years. Since the 1918 pandemic, with rare exceptions, the H5N1 virus is the only avian influenza virus that has shown a consistent and persistent ability to cross the species barrier and directly infect humans to cause severe disease without the need to acquire human-adapted genes through reassortment with human influenza viruses, ie the pandemic risk from H5N1 is different in nature from the 'milder' pandemics of 1957 and 68 caused by reassortment of seasonal flu viruses, and significantly more serious than the normal 'background' pandemic risk from any other influenza virus at any other time in our known history. Further discussion on this topic is continuing at the Flu Wiki forum Competing interests: None declared
FAFfing about 30 June 2007
Sheila A Edgar, Homemaker n/a Send response to journal: Re: FAFfing about	In response to your article, I would like to bring this to your attention. Suggested citation for this article: Maas R, Tacken M, Ruuls L, Koch G, van Rooij E, Stockhofe-Zurwieden N. Avian influenza (H5N1) susceptibility and receptors in dogs. Emerg Infect Dis. 2007 Aug; [Epub ahead of print] Avian Influenza (H5N1) Susceptibility and Receptors in Dogs *Wageningen University and Research Centre, Lelystad, the Netherlands Inoculation of influenza (H5N1) into beagles resulted in virus excretion and rapid seroconversion with no disease. Binding studies that used labeled influenza (H5N1) showed virus attachment to higher and lower respiratory tract tissues. Thus, dogs that are subclinically infected with influenza (H5N1) may contribute to virus spread. Quote: Influenza virus infection of dogs was first reported in 2004. Influenza (H3N8) of equine origin caused outbreaks in greyhounds in Florida and has since been found in dogs in >20 US states. The course of experimental infection of SPF dogs with subtype H5N1 resembles that of the experimental infection of dogs with the subtype H3N8: all dogs seroconverted, and some excreted virus without obvious disease. Quote: Inoculation of influenza (H5N1) into beagles resulted in virus excretion and rapid seroconversion with no disease. Binding studies that used labeled influenza (H5N1) showed virus attachment to higher and lower respiratory tract tissues. Thus, dogs that are subclinically infected with influenza (H5N1) may contribute to virus spread. Quote: Avian influenza (H5N1) virus has been shown to be infectious not only for birds but also for humans and mammals such as mice, ferrets, and cats. Quote: Carnivorous mammals that are susceptible to subtype H5N1 may contribute to spread of the virus; shedding of influenza (H5N1) by pet carnivores may pose a risk to humans. Quote: Our results demonstrate that dogs are susceptible to infection with avian influenza (H5N1) virus and can shed virus from the nose without showing apparent signs of disease. Moreover, receptors for avian (H5N1) virus are present not only in the lower part of the respiratory tract of dogs but also in their trachea and nose, which are potential portals of entry for the virus. Quote: In contrast to the experimental outcomes, natural infections with influenza (H3N8) resulted in serious illness, death, and widespread infection for dogs. This finding warrants special attention to the potential course of avian influenza (H5N1) infection in dogs. Therefore, dogs’ contact with birds and poultry should be avoided in areas with influenza (H5N1) outbreaks to prevent possible spread of virus and human exposure to influenza (H5N1) virus that might have been adapted to mammals. http://www.cdc.gov/eid/content/13/8/pdfs/07-0393.pdf Competing interests: None declared
Hope is not a plan. A plan is not preparedness. 30 June 2007
Joel H. Jensen, Health Care Attorney Minnesota , USA 55416 Send response to journal: Re: Hope is not a plan. A plan is not preparedness.	You ask: "Couldn't those responsible for planning for the next pandemic do their planning less publicly and put the frighteners on the rest of us at the appropriate time?" And therein lies the problem. The appropriate time is today - well in point of fact, yersterday. If all we do now is plan all we will have to protect us tomorrow are plans. Just as hope is not a plan, plans are not preparedness. We must have both the capacity and the willingness to respond. That means taking action now so that when, not if, a pandemic does occur we will be ready for the worst. We have had some examples over here of what happens if you do not pay attention to the levees or to predictions of terrorist acts. Hurricanes happen. Towers can fall. If today we have the science that allows us to identify when a pamdemic may be less uncertain than it was before, we would be grossly negligent if we did not urge every measure we can manage to prepare us for that possible event. Competing interests: None declared
Questions to Greg Dworkin. 30 June 2007
Hilary Butler, freelance journalist. Home, Tuakau 2121 New Zealand. Send response to journal: Re: Questions to Greg Dworkin.	1) Is worldwide pandemic planning suddenly a seriously considered issue because of **ONE** example where a child passed the virus to father, and the father passed it to no-one else? (Do we really know that the father hadn't also handled a bird?) 2) Was the cluster in Egypt as alleged by the lady above, PROVEN to also be human to human transmission? 3) If the issue is generalised pandemicity planning more focused to human H1,2,and 3,then why not say so, rather than flogging a 10 year bird flu frenzy which so far has come to little..., which may simply be seen later, as yet another of the many SARS-type crying wolf scenarios? Sincerely, Hilary Butler. Competing interests: None declared
False assumptions about the speed and limits of evolving viruses 30 June 2007
V. Switzer, ARNP, occupational infectious disease EHPEC Employee Health, 98005, Bellevue, WA Send response to journal: Re: False assumptions about the speed and limits of evolving viruses	Sir, Your assumption that having first identified the influenza strain, HPAI H5N1 in 1997 we should therefore have seen adaptation to humans by now, is naive. First, we have no experience from which to draw a conclusion about the length of time we should expect to see changes within. It has not yet been determined, to my knowledge, how long the 1918 influenza circulated in birds before adapting to humans. We have, I believe, determined the 1918 virus is more closely related genetically to avian strains of influenza than human strains suggesting a rapid species jump. Avian influenza virus has exhibited rapid evolutionary dynamics. (1) In addition, it is well documented that two pandemics since 1918 were the result of reassortment. It has also been observed that there is a wide range of genetic exchange occurring within the H5N1 clades. The viral strains are not only evolving, they appear to reassort on a regular basis.(2) It is believed only a few genetic changes may be required for HPAI H5N1 to acquire the ability to spread between humans.(3) There is also evidence high lethality potentially requires only a minimal change.(4) Such changes can occur by either mutation or reassortment. H5N1 need only acquire a single gene from a human influenza strain, and likewise a human influenza strain may only need a small segment of the H5N1 genome to acquire high lethality. Since 1997, the HPAI H5N1 strain has spread across Asia, all but the most western countries in Europe, the Middle East and as far south in Africa as Nigeria and Togo. Efforts to eliminate the virus have failed and the virus can be expected to be around for a long time to come. It is far from time to call this strain a no show as the cause of the next human influenza pandemic. We will unlikely be able to breathe a sigh of relief over this influenza strain until it becomes attenuated in the bird populations which are still suffering high fatality rates from it. As long as a genome segment with such extreme lethality is circulating so widely, mutation or reassorment resulting in a new highly lethal human strain will remain a very serious risk. (1)http://mbe.oxfordjournals.org/cgi/content/abstract/23/12/2336 Molecular Biology and Evolution 2006 23(12):2336-2341; Avian Influenza Virus Exhibits Rapid Evolutionary Dynamics; Rubing Chen* and Edward C. Holmes (2)http://vir.sgmjournals.org/cgi/content/abstract/87/10/2803 J Gen Virol 87 (2006), 2803-2815;Genotype turnover by reassortment of replication complex genes from avian Influenza A virus; Catherine A. Macken1, Richard J. Webby2 and William J. Bruno (3)http://jvi.asm.org/cgi/content/full/79/17/11533?view=long&pmid=16103207 Journal of Virology, September 2005, p. 11533-11536, Vol. 79, No. 17; A Single Amino Acid Substitution in 1918 Influenza Virus Hemagglutinin Changes Receptor Binding Specificity; Laurel Glaser, et al (4)http://jvi.asm.org/cgi/content/abstract/81/4/1838 Journal of Virology, February 2007, p. 1838-1847, Vol. 81, No. 4; Amelioration of Influenza Virus Pathogenesis in Chickens Attributed to the Enhanced Interferon-Inducing Capacity of a Virus with a Truncated NS1 Gene; Angela N. Cauthen,et al. Competing interests: Owner/sole proprietor of an employee health practice with a focus on occupational infectious disease
Re Hilary Butler's questions 30 June 2007
Greg Dworkin, MD, pediatric pulmonologist Danbury, CT 06810 Send response to journal: Re: Re Hilary Butler's questions	Ms. Butler, these are good questions, and ones that have been debated rigorously both in scientific and public circles for a year. As to the idea of what it takes for someone to know without a reasonable doubt that A has led to B, in the case of the cluster in Indonesia in 2006, it seems very clear there was human to human transmission as WHO states. Their conclusion is based on genetic sequencing as well as field study. In that case,the virus quite possibly passed to other relatives. WHO is very careful to conduct on-the-ground epidemiological investigations before coming to such a conclusion and is extremely conservative about same. The earlier Vietnam case took a year before being published in the NEJM by Ungchusak et. al. The Egyptian case is under investigation, but any cluster is cause for concern and calls for rigorous study. Also, in Indonesia, you should be aware that 20% of the time, poultry or bird handling cannot be determined. Cats and other mammals are also affected and may be an important vector (under study in Indonesia, the Netherlands and elsewhere). As to the broader question of whether concern revolves around a single case, no. It revolves around three concepts. One is that there are over 300 documented cases of human H5N1 infection from whatever source (a case a week, on average), and there's a 60% mortality rate. That is not a single case. Each case has the potential to produce mutations that are better adapted to humans. Two, pandemics happen. We can say with 100% certainty there will be another. We don't know if it'll be the H7 seen in Wales, the H5 seen in SE Asia and Egypt (a leading candidate) or an as yet unknown flu virus but a pandemic will happen. If it is is H5N1 that is a catastrophic event. Catastrophic events require planning, and as I referenced above, eevn mild pandemics will overwhelm the US health care system and (I suspect) the UK's as well. Three, I would recommend you carefully read Canada's SARS Commission after-action report and be familiar with the precautionary principle: action to reduce risk should not await scientific certainty. More here on that, but the relevant bit is: We must remember SARS because it holds lessons we must learn to protect ourselves against future outbreaks, including a global influenza pandemic predicted by so many scientists. If we do not learn from SARS and we do not make the government fix the problems that remain, we will pay a terrible price in the next pandemic. (bolded mine). Prudence dictates that reasonable steps be taken to bolster both personal and institutional preparedness, steps which can help with any hazard that then comes. This is not idle speculation, and it is action supported by multiple governments and health agencies, as well as businesses, NGOs, scientists and individuals around the world. Competing interests: None declared
Pandemic Insurance 30 June 2007
Peter Dunnill, Chairman ACBE, University College London Send response to journal: Re: Pandemic Insurance	To: Editor, British Medical Journal I was concerned by the deliberately offensive tone of the deputy editor Tony Delamothe who attacks those working to address the possibility of an influenza pandemic (June 29th BMJ). There may be rather too many international meetings and media reports do on occasion amplify the genuine and wide spread concerns of many knowledgeable scientists. However, given the general apathy, particularly in Europe, it is necessary for those of us who are preparing affordable plans to find ways to address the public. Otherwise they would have no counter to the complacency which the editorial encourages. With my co-author David Fedson I have focussed particularly on how new vaccines which are already approved for seasonal influenza or are very close to approval could be produced in existing vaccine and biopharmaceutical protein facilities (Fedson and Dunnill, 2007). This would avoid the capital costs of hundreds of billions of dollars globally to match the US current pandemic preparedness investment. However, it would require time consuming, though relatively inexpensive, negotiations on intellectual property and technology transfer. The activity has no commercial incentive so governments would need to enable it. They will not do that if the medical establishment constantly argues it is unnecessary. Pandemic preparedness is like house insurance: one hopes not to need it but if a severe pandemic comes then as things stand the total global vaccine capacity with the very best adjuvant could after 6 months cover only 700 million of the 6400 million global population, and that will not change in the next 10 years. For the rest the situation could be essentially the same as in 1918 since antibiotics do not seem to be of great significance. Tony Delamothe maybe happy to have that on his conscience, I am not. Peter Dunnill, OBE, DSc, FREng, Chairman, The Advanced Centre for Biochemical Engineering, Dept. of Biochemical Engineering, University College London, Torrington Place, London WC1E 7JE, UK Tel 0207 679 7031, Fax 0207 209 0703 ; E.mail: p.dunnill@ucl.ac.uk Fedson, D.S., Dunnill, P. New approaches to confronting an imminent influenza pandemic. The Permanente Journal 2007; 11, 63-9. Competing interests: None declared
correction 30 June 2007
Greg Dworkin, MD, pediatric pulmonologist Danbury, CT 06810 Send response to journal: Re: correction	the NEJM case was in Thailand, not Vietnam. There was a Vietnamese nurse who became ill, apparently after patient contact, but that was a different case. WHO is separately aware of it. Competing interests: None declared
Re: False assumptions about the speed and limits of evolving viruses 30 June 2007
Edna Mode, Writer, editor, pandemic planner New England Send response to journal: Re: Re: False assumptions about the speed and limits of evolving viruses	Bravo V. Switzer for calling out the strawman argument being made by Hilary Butler and Tony Delamothe. To assume that H5N1 will not start an influenza pandemic because it has not done so in the 10 years since it first infected humans is entirely fallacious. Technology today allows us to exchange and track information practically in real-time. No such documentation of past pandemics is available. Historical records are sketchy at best. And while today's scientists, such as Jefferey Taubenberger and Robert Webster, attempt to understand the evolution of pandemic viruses, the truth is we simply do not know how long previous zoonotic strains circulated causing illness in small clusters of humans before gaining pandemic efficiency. Journalists bear a particular responsibility to report on such an important topic from an informed perspective. For anyone who spends even a half hour researching H5N1's evolutionary track, it is clear that the virus is on a course to gain efficient transmissibility. Yes, it is possible that nature may choose a different course, but it isn't looking likely. Apparently H5N1 is not evolving to that endpoint quickly enough for the likes of the Tonys and Hilarys of the world. For those journalists skeptical of all the "FAFfing about" on pandemic: Since you clearly won't be devoting any time to preparing your communities and families for pandemic, perhaps you should use the time left to consider what your response will be to the outraged public following the coming pandemic--the same public that relied on you for accurate information before the pandemic. That, of course, assumes you are still around to respond. With H5N1's current case fatality rate of more than 60%, that's unlikely. Competing interests: None declared
AIDS was once jsut 191 victums 1 July 2007
Kobie A Marou, Computers Chesapeake, Va 23322 Send response to journal: Re: AIDS was once jsut 191 victums	Mr. Delamothe, Yes we are trying to keep the nightmare alive, front and center as another virus for which we have no defense marches forward. Not a solution looking for a problem but another risk to manage. Beneifits:get people ready. Being ready for a pandemic is being ready for other disasters. That is a good thing. I am just trying to keep people up to speed and the right way round as FAF ponder the worse and how to avoid it. Regards and respect sir, Kobie Competing interests: None declared
On the nature of concerned peoples 1 July 2007
Ellen Rice, homemaker 98502 Send response to journal: Re: On the nature of concerned peoples	I started learning about the H5N1 virus three years ago because we kept chickens and my husband's work occasionally took him to Asia. I was worried he might bring home a bug that would hurt our little flock. Very soon I was thinking "Forget the birds! What about our kids?" My efforts to learn as much as possible led me to a variety of "flu boards". Yes, there are people who seem to spend enormous amounts of time in communication about the H5N1 virus -- but the vast majority are sincere, thoughtful, well educated and clearly have obligations and passions aside from H5N1. In fact, it is their dedication to their families and communities that make them so keen to watch and discuss "avian flu." As a homemaker in a rural community, I have experience with gossipy old biddies who have pots of time on their hands and who like to stir up trouble with the disaster de jure. That sort is the polar opposite of the deeply concerned and profoundly professional sorts who are trying to sieve through the H5N1 information as it becomes available in order to best serve their families, their nations and their world. Shame on you, sir, for slandering the latter by implying they are the former. You are sly. You are smug. You are not at all helpful. Competing interests: Severe allergic responses to idjits and smug uns.
Evaluating Pandemic Risk 2 July 2007
Susan Chu, Editor, Flu Wiki Oxfordshire, OX7 4HT, UK Send response to journal: Re: Evaluating Pandemic Risk	Thank you, Prof Dunnill, for raising the issue of pandemic insurance, which is where the gist of the debate should lie. Let me also propose a response to this particular question from Mr Delamothe But why should we be any more worried in 2007 than in 1997 or 2017? The answer to that question lies in the fact that there are certain observable biological events (eg repeated human infections by a novel avian virus) that are potential precursors to a pandemic which may give us some forewarning of what might be imminent, a luxury that previous generations did not have. To the extent that advances in virology and epidemiology have made it possible for us to document such changes in the behaviour of viruses, it would be foolish, indeed irresponsible, for us to not make use of the information available. This is exactly the same as how one would use weather forecasts or flood or hurricane warnings to inform one’s behaviour. Let’s take hurricanes, using the example of Katrina and New Orleans. On any given day, any given town faces a hypothetical risk of a direct hit by a hurricane. One can estimate that risk from how many hurricanes happen per year and how often they hit a particular area. The answer for most people is that the risk is very low indeed, just as one can say pandemics happen on average ‘only’ about 3 times each century. On the other hand, if a hurricane has already formed over the ocean, and it is picking up speed and strength and headed your way, most of us would start paying attention, if only to check the weather warnings more frequently. If this is more than your normal run-of-the-mill hurricane, if you have been told that a Category 5 hurricane is headed in your general direction and may hit in the next 24-48 hours, would it not be prudent to assume you are likely to suffer a direct hit and make preparations accordingly? Of course, the hurricane can still weaken, as they often do, after they hit land and before arriving in your area. Or it may become deflected and hit some other area instead. But you don’t know that ahead of time, and waiting around to find out may mean missing the chance to save yourself, as tragically many found in New Orleans. In addition, some of the defences that we take for granted, be it levees or healthcare services, may fail if the catastrophe is big enough. I would submit, therefore, that With regards to H5N1, we are, at the current time, at exactly the same position as New Orleans 24 hours before Katrina hit. As for this next question Couldn't those responsible for planning for the next pandemic do their planning less publicly and put the frighteners on the rest of us at the appropriate time? let me refer you to the words of Dr David Heymann, Executive Director, Communicable Diseases, World Health Organization, written in the foreword of this most excellent booklet compiled by a community of volunteers, Influenza Pandemic Preparation and Response: A Citizen’s Guide, (italics mine). Public health authorities throughout the world agree that the responsibility to respond to a public health emergency such as pandemic influenza cannot be fully placed under the responsibility of health workers and other primary responders, who may themselves become incapacitated by illness and death. It is thus each individual’s responsibility, alone or collectively, to plan for and respond to a pandemic in the home and/or in the community. Competing interests: None declared
A long fast? 2 July 2007
Jane Lawrence, retired 60202 Send response to journal: Re: A long fast?	Mr. Delamothe, Have you thought about the source of your meat and drink (or your daily bread) after a pandemic starts? Even if you manage to avoid infection, do you imagine that your life will be the same as now, with lorries of groceries delivered to shops daily? We FAFfers have been thinking about food and water and other likely system failures that will be the consequence of 40 to 60% of workers being absent from their jobs during a 6 to 8 week wave of influenza. (And, there will be more than one wave.) That includes hospitals, of course; lack of staff and increasing numbers of the ill means that only the first flu victims will receive 21st-century care. The later victims will be lucky to have a drink of water and clean sheets. These unfortunates would be better off being nursed at home, if only their families knew how, and had the fever reducers and oral rehydration solution ingredients they would need. Do you begin to understand the magnitude of the pandemic problem, and why we FAFfers stay focused? Becoming self-sufficient for weeks on end cannot be accomplished overnight, and most people haven't even begun. There has been progress in the treatment of HIV/AIDS, but much of it depends on drugs. What will become of a patient whose health depends on a constant supply of pharmaceuticals, when the drugs are no longer in stock at the chemist's or at the hospital? Fear at these realizations isn't something to turn away from; ignoring these issues won't make them go away. "It won't happen to me" didn't work with HIV, and it won't work against an influenza virus. Competing interests: None declared
Has the BMJ Gone a Bit Too Far? 2 July 2007
Jay Ilangaratne, Founder www.medical-journals.com Send response to journal: Re: Has the BMJ Gone a Bit Too Far?	If the purpose of this column was simply to attract a high number of responses,then Mr Delamothe may have already succeeded. However,sadly, the provocative title he has chosen and bewilderingly disproportionate ranting against those who strive to keep an important public health isssue alive do not conform with responsible medical journalism. More so, as succintly pointed out by some already, Delamothe's criticism seems to be rather short on scientific facts in relation to H5N1 or its possible future course but an attack based on comparison with road deaths and AIDS. He also attempts to demean those Avian Flu campaigners by saying "it has killed just 191 people";that is an extremely naive analogy by any standards to devalue the attempts of those disease-prevention campaigners whom he berates so heavily. Ironically, Delamothe himself states "as influenza H5N1 is proving particularly resistant to undergoing the killer mutation that would allow efficient human to human transmission of the virus";with strong possibility(if not probability) of such alarming consequences to the entire human race,it is surprising indeed that Delamothe felt apt to address this issue in the manner he had done. Perhaps,the BMJ Editor would care to exercise more editorial control and ensure that only more logical and constructive criticism is published in the future. Competing interests: None declared
AIDS is not such a big problem 2 July 2007
Dave Null, seated - Send response to journal: Re: AIDS is not such a big problem	AIDS is a far easier disease to keep yourself safe from than flu. HIV isn't very infectious - all that's needed is education. Harsh but true: in general the educated/smart ones will live and the ignorant or stupid/undisciplined will die. Sure there will be exceptions, but they will remain exceptions and few (unless HIV mutates to become far more infectious). In contrast flu and malaria are all more infectious than AIDs. A country can operate fairly effectively even with a fair number of HIV infected people scattered amongst its population. The quarantine/safety methods (condoms, monogamy etc) allow society and systems to operate fairly "normally". Whereas if there are a few hundred scattered with _deadly_ flu in the country and there is no cure/vaccine, the quarantine methods could severely affect the country's systems. So from the big picture point of view, I don't see AIDS as a big problem, sure some countries have an AIDS problem, but the main reason why they have an AIDS problem is because they have some other bigger problem - an uneducated population and/or the wrong people in charge. And those far bigger problems would cause them other trouble even if AIDS wasn't around or there was a cheap cure for it. Competing interests: None declared
FAFfing about 2 July 2007
Dr Frank Wells, Chairman, BMA Retired Members Forum BMA, WC1H 9JP Send response to journal: Re: FAFfing about	Regardless of Delamothe's plea for less public planning for pandemic flu1 there is a need to identify in advance personnel, over and above those already working in health care, who would be willing to assist if and when pandemic influenza occurs. Such personnel include retired doctors and, in this context, the BMA Retired Members Forum has taken two initiatives: the first is to establish a database of those retired members willing to be contacted as experienced pairs of hands; and the second is to contact those responsible for retired members' organisations within the medical royal colleges to augment that database. The BMA is represented on the relevant planning groups where such matters as GMC registration and indemnity are being discussed. The database is being co-ordinated by the Retired Members Forum secretariat. Retired doctors willing to be contacted should submit their geographical location and e-mail address to Catharina Ohman at COhman@bma.org.uk Frank Wells Old Hadleigh, London Road, Capel St Mary, Ipswich IP9 2JJ 1. Delamothe T. FAFfing about. BMJ 2007; 334: 1325 (30 June) Competing interests: Chairman, BMA Retired Members Forum
Envisioning the worst 3 July 2007
David S. Fedson, Retired academic physician 57, chemin du Lavoir, 01630 Sergy Haut, France Send response to journal: Re: Envisioning the worst	Tony Delamothe would have us focus on the apocalypse that is already upon us (HIV/AIDS) rather than on a future event that has been revealed only to a few Friends of Avian Flu. Yet he must know that nothing in Darwinian evolution says that human beings are to be uniquely spared rapidly climactic events. The mortality experience of several mammalian populations should be instructive: in the early 1980s, 20% of the harbour seals along the New England coast died within a few months of avian H7H7 influenza. During the same period, one-third of the lions in the Serengeti died of distemper, and more recently one-quarter of the gorillas in Central Africa have died of Ebola virus infections. Population die offs of lesser species occur unnoticed all the time. Moreover, as far as we know, the influenza virus doesn't need human hosts; as long as there are birds to infect, we could disappear and the virus would carry on undisturbed. But with its restless genome, it can reassort or mutate and infect seemingly untouchable species with sudden and catastrophic consequences. One such example was given by Robert Webster and his colleagues many ago (The "in vivo" production of "new" influenza viruses. 3. isolation of recombinant influenza viruses under simulated conditions of natural transmission. Virology 1973; 51: 149-62). In this experiment, all of the animals exposed to a new influenza virus reassortant died. Since the same thing could (and for some avian species probably has) occurred again, the Friends of Avian Flu believe we should take measures to prepare. That by and large we have failed to do so speaks to our cultural inability to "envision the worst", as recently pointed out by Karen Cerulo in her splendid book "Never saw it coming." Like most people, Delamothe seems unable to "envision the worst", and consequently he downplays our efforts to prepare. His counsel is both reckless and deeply uninformed. Competing interests: The author has received travel expenses and occasional honoraria for lectures on pandemic influenza given at international scientific meetings.
Promotional healthscares 4 July 2007
John Stone, none London N22 Send response to journal: Re: Promotional healthscares	There always remains the issue of whether scares are being promoted because of sober assessment of risk or because they constitute another bonanza for the pharmaceutical industry. We need better institutional means to spot the difference (heartening at least that it seems to have divided government in this country), but so far pandemic flu has been dissappointing for the horror merchants. It has be going to engulf us all for at least two years now. At least we know that some of dudgeon here is likely to be connected with an urgent notice on another forum: http://www.newfluwiki2.com/showDiary.do?diaryId=1395 Does anyone recall the moral of the story of the little boy who cried wolf? Well, it is what the industry does all the time. Competing interests: None declared
re John Stone's comment 6 July 2007
Greg Dworkin, MD, pediatric pulmonologist Danbury, CT 06810 Send response to journal: Re: re John Stone's comment	Rather, you mean the dudgeon at the Forum site you list is engendered by the editorial here. It is actually non-pharmaceutical intervention, including potential school closures/student dismissals, alternate care sites for overwhelmed hospitals, and social distancing which are at the forefront of pandemic planning. The US Center for Disease Control's Community Strategy for Pandemic Influenza Mitigation exemplifies this. Americans are all too familiar with the disaster in New Orleans after Hurricane Katrina hit. Strengthening the levees prior to a storm, and rehearsing via evacuation drills seem prudent and minimal steps whereas complaints that 'disaster hasn't hit, therefore it must be hype' seem rather quaint. I would respectfully suggest one should approach pandemics the same way as one should hurricanes, and do one's homework (read the CDC report) before anyone dismisses this as pharmaceutical hype. After all, vaccine jabs won't be available until starting at least six months after a pandemic hits, and there won't be enough antivirals to go around. Competing interests: None declared
Re: Promotional healthscares 8 July 2007
Susan Chu, Editor, Flu Wiki Oxfordshire X7 4HT Send response to journal: Re: Re: Promotional healthscares	I would like to thank John Stone for bring the readers' attention to the issue of 'healthscare promotion' vs 'sober assessment of risk'. Regrettably, he failed to point out that the particular forum discussion for which he posted the link arose in response to this distinctly un-sober assessment by BMJ in the first place! Whilst we do not aspire to the wide readership nor the standards of expert review that prestigious journals like the BMJ maintain, we do take seriously our responsibility of informing the public as accurately as possible, and in language that the general public can understand. Perhaps Mr Stone can so some 'sober assessment' of his own, by reviewing some of the forum discussions on pandemic-related issues of vital public interest, such as these ones on 2006 year end review H5N1 as pandemic threat, Tamiflu - Efficacy and Resistance, and Non-pharmaceutical Interventions - Lessons from 1918 before deciding that those who are concerned about and working towards overcoming the challenges that a pandemic could bring are crying wolf. Competing interests: None declared
Re: Promotional healthscares 8 July 2007
V. Switzer, ARNP, occupational infectious disease EHPEC Employee Health, 98005, Bellevue, WA Send response to journal: Re: Re: Promotional healthscares	You've noted a number of important issues but failed to keep them separate. The vast majority of researchers and health care providers involved in pandemic flu research or preparedness are not involved in pharmaceutical promotions of profit making drugs, nor are they encouraging reporters to exaggerate any threats. Unfortunately to many members of the public, those researchers and health care practitioners are almost invisible. Pharmaceutical promotions are common. I have not seen Tamiflu promoted on any grand scale. There's no need. Roche can't keep up with production as it is. There may be some drug company involvement in pandemic flu circles but they do not dominate the field by any means. The mainstream news is a commodity, produced in the same frameworks regardless of the facts. Everything science must have 2 sides, a controversy, as if scientific evidence never actually provides any answers. Quack medicine and junk science get equal time. If it isn't a looming disaster, the public tires. So the news media switches to the scandal of public officials crying wolf. A single study with a sample size of 15 means "a big breakthrough". If I had a nickel for every time the news reported cancer was practically cured, I'd be rich. As researchers and health care providers we are not yet good at using the news to actually communicate with the public. The recent case in the news of the 'TB on a plane scare' was a classic example. The CDC did a terrible job communicating the minimal risk to the public our traveling attorney actually posed. In order to contact the air travel passengers on the flights the source case was on, CDC announced that something akin to a deadly plague was on the flights. This guy's father-in-law, working on TB research at the CDC wasn't even aware of this newly suspected risk of smear negative, culture positive TB cases accounting for some spread of TB. Considering that even with smear positive cases, the risk of TB spread on planes is extremely low, surely this risk was blown way out of proportion by the CDC's Director, Dr Gerberding herself. But I don't believe Dr Gerberding had some desire to broadcast fear to the public. Instead, the problem is the poor job we have done in the scientific community of using the media under our terms, and of having our voices heard. The public is exposed to advertising campaigns and the news commodity framework, both of which are poor educators. The public is cynical, sometimes believing we are all in on some big pharmaceutical scheme. Some of us joke, if that's true, where's our cut? Researchers and health care practitioners are a silent majority. The scientific community needs to find its voice. The public needs to know there are scientific experts out there who are simply interested in where the evidence leads. The public needs an education in critical thinking skills. They need to recognize scientific research actually does get it right and we aren't divided 50:50 on very many issues. Most importantly, because I believe an informed pubic is critical, the news media has to break from its stupid formula news. Those of us in the medical and other scientific fields need to insist on junk and quack science not being given equal billing simply because the formula news has always done it that way or because the reporters cannot distinguish the difference. We need to educate reporters in science and critical thinking. We need more Union of Concerned Scientists and other professional and scientific groups that can earn and maintain the public trust. When corporate interests get in the way of an informed public either for some direct financial interest or because they've turned the news media into what sells over what informs, then the public should know it can turn to the professionals and the scientists for reliable information. That little boy who cried wolf really did need to be heard but by then no one was listening. We are at that point, but not because scientists have cried wolf, because we have not spoken out above the other people crying it. Competing interests: Owner/sole proprietor of an employee health practice with a focus on occupational infectious disease
Re: Re: Promotional healthscares 9 July 2007
John Stone, none London N22 Send response to journal: Re: Re: Re: Promotional healthscares	I thank everyone for their response. I note the wide range of professional views available. For instance, Sir David King, Chief Government Scientist: "The chances of bird flu virus mutating into a form that spreads between humans are "very low", the government's chief scientific adviser has said. "Sir David King said any suggestion a global flu pandemic in humans was inevitable was "totally misleading"." (9 April 2006) Or on the other hand, Sir Liam Donaldson, Chief Medical Officer: "The Government's Chief Medical Officer, Sir Liam Donaldson, told Andrew that a bird flu pandemic could result in at least 50,000 excess deaths in this country. "Sir Liam said that higher estimates of deaths up to 750,000 from a future pandemic were "not impossible" although he added that: "I think it is more realistic that the figure will be a lot lower than that." " (16 October 2005) In one sense I do not pretend to know, but I wonder why it was that people were suddenly predicting that a strain of bird flu which has been waxing and waining for decades was just about to mutate and jump the species barrier. I should imagine this is where Sir David comes from on this. I recall early last year a Government minister stating that according to his information,the longer a strain had been around the less likely such a jump was. I guess he had been speaking to Sir David and not Sir Liam. And it obviously is a bonanza for some: this journal has reported on the tamiflu issue. Another question I would have is how you can invest in a vaccine for a virus which so far does not exist? And how can you assess its efficacy and safety? I wish everyone good luck. [1] http://news.bbc.co.uk/1/hi/uk/4893366.stm [2] http://news.bbc.co.uk/1/hi/programmes/sunday_am/4347104.stm Competing interests: None declared
Re vaccines, predictions, etc 11 July 2007
Greg Dworkin, MD, pediatric pulmonologist Danbury, CT 06810 Send response to journal: Re: Re vaccines, predictions, etc	John Stone brings up some important points that do deserve clarification. In one sense I do not pretend to know, but I wonder why it was that people were suddenly predicting that a strain of bird flu which has been waxing and waining for decades was just about to mutate and jump the species barrier. Recent papers (including by Webster (H5N1 Influenza — Continuing Evolution and Spread) and Taubenberger, et al (The Next Influenza Pandemic - Can It Be Predicted?) and Peiris and de Jong (Avian Influenza Virus (H5N1): a Threat to Human Health) make clear that the next pandemic cannot be predicted. That's a two-edged sword because there is no scientific reason for H5N1 to not be the next pandemic, and given its continued human infection pattern and endemic nature (it is too late to eradicate it from SE Asia and even Europe has recurring H5N1 bird infections), it remains a pandemic candidate. The emphasis, therefore, is on preparedness rather than prediction. If one knows that category 5 storms exists, they need to be included in the planning. Quoting Webster from the New England Journal of Medicine: H5N1 Influenza —Continuing Evolution and Spread Robert G. Webster, Ph.D., and Elena A. Govorkova, M.D., Ph.D. Clearly, we must prepare for the possibility of an influenza pandemic. If H5N1 influenza achieves pandemic status in humans -- and we have no way to know whether it will -- the results could be catastrophic. Quoting Taubenberger, et al: Thus, it is essential that while carefully monitoring current and identifiable risks, pandemic prevention strategies must also be based on expecting the unexpected and being capable of reacting accordingly. Quoting Peiris: The highly pathogenic avian influenza virus subtype H5N1 is already panzootic in poultry, with attendant economic consequences. It continues to cross species barriers to infect humans and other mammals, often with fatal outcomes. Therefore, H5N1 virus has rightly received attention as a potential pandemic threat. However, it is noted that the pandemics of 1957 and 1968 did not arise from highly pathogenic influenza viruses, and the next pandemic may well arise from a low-pathogenicity virus. The rationale for particular concern about an H5N1 pandemic is not its inevitability but its potential severity. An H5N1 pandemic is an event of low probability but one of high human health impact and poses a predicament for public health. Regarding vaccine, it is difficult to know about vaccine efficacy prior to an actual pandemic. Antibody response to test antigen can be checked (that's how we know the current pre-pandemic vaccines are weakly effective), but that is also why the bulk of preparedness dollars go to vaccine R&D. We need better production and distribution methods (and not for the US alone!). That gets back to Tony's comment: Couldn't those responsible for planning for the next pandemic do their planning less publicly and put the frighteners on the rest of us at the appropriate time? The clear answer is "no". It may be that in a pandemic, vaccine strategies are altered, with vaccine geared toward children rather than the elderly (where it may work better to keep disease from spreading). Vaccine may also have to be rationed and allocated. This is more than academic, and needs careful study (and oversight!) during this, the interpandemic period, so rational decisions can be made, with public input. Without that input, rationing strategies will fail. Without discussion, there is no input. Competing interests: None declared
Re: Re vaccines, predictions, etc 13 July 2007
John Stone, none London N22 Send response to journal: Re: Re: Re vaccines, predictions, etc	I am once again grateful to Greg Dworkin for his response. Is it not the case that the probability of a pandemic has been greatly over-hyped? I could have sworn, for instance, that the BBC report of Andrew Marr's interview with Sir Liam Donaldson (which I quoted form above), has been toned down in the past two days. I am currently trying to track down the original text. But I quote from the publicity for the BBC Horizon programme last November: "A simple virus brewed in the belly of a dead bird is set to embark on a global killing spree. The likely culprit is H5N1 - a bird flu virus with the dangerous potential to mutate into the next pandemic flu virus. "In a feature-length special, we tell the story of what could happen if a flu pandemic hits. Experts predict the next pandemic will be more disruptive than any disease we've seen before. And they're particularly worried that it will be most deadly for the young and otherwise healthy." http://www.bbc.co.uk/sn/tvradio/programmes/horizon/broadband/tx/pandemic/ But H5N1 was first identified in Scotland in 1959. It is not suprising that it presents a serious local hazard to the bird-handling poor of the developing world, but what was basis for saying after half a century it was set to mutate in the horrific way that was being billed? I note the far more cautious terms of the studies cited by Dr Dworkin. Competing interests: None declared
The State of FAF (Fear of Avian Flu) 13 July 2007
Luc G. Bonneux, Sr researcher NIDI, 2502 AR Den Haag Send response to journal: Re: The State of FAF (Fear of Avian Flu)	A great editorial in splendid writing. There is nothing wrong in preparing for a serious epidemic of respiratory disease. However, we are unable to predict these epidemics, their spread, the type of the virus, the severity of the affection and where they will come from. SARS came out of the blue, as will the next epidemic. There is risk (a probability that something will happen), uncertainty (the uncertainty surrounding that probability) and surprise (shit happens). The Spanish Flu was a surprise attack of avian flu. It happened once, never before, never thereafter. The other pandemics are normal flu pandemics, killing the weak and old. A general rule of surprises is that what you predict will not happen, and what will happen will not be predicted. Treat risk and prepare for a surprise attack, but not for avian flu. Even in the twentieth century, more people died of "normal" flu, a known risk, than of "avian Spanish" flu, a surprise. A part of the pandemic of fear has been generated to sell neuraminidase inhibitors, expensive drugs not supported by any robust evidence of clinical effectiveness, let alone cost-effectiveness. Worldwide, billions have been wasted. It needs weathered cynicism to enjoy this absolutely brilliant marketing by fear. However, nobody doubts the role Big Farma has to play, which is making, promoting and selling drugs. They didn't do wrong. The wrongdoers are "independent" advisors from bureaucracy and academia. First, the growing bureaucracy has to prove its reasons of existence. FAF activity may be used as a benchmark of useless bureaucracy. If you have time to spend in making reports about the unpredictable and the unforeseeable, you have too much personnel for too few true problems. Second, universities became enterprises that need to extract immer increasing amounts of research money out of a scarce markets. Influenza was bugging research groups - for many decades no pandemics, even no serious epidemics occurred. In the State of FAF, peer leaders in virology saw their window of opportunity. The many links with pharmaceutical industries in financing the ever bigger and ever more expensive labs likely didn't help. We need a more critical appraisal of the role of academic experts - academia is endangering its only truly valuable merchandise: integrity. Competing interests: None declared