H5N1 influenza and the implications for EuropeBMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7514.413 (Published 18 August 2005) Cite this as: BMJ 2005;331:413
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EDITOR- As an anaesthetist I have been considering how I might protect myself if a 'flu pandemic heads my way. If it breaks out soon then I think it is obvious that we are not ready. Nabarro of the World Health Organisation has already admitted this.
The government has ordered 14.6 million doses of Oseltamivir (Tamilflu) but this order will only be complete in September 2006 and may well turn out to be useless because H5N1 has already shown resistance to this drug.
There will not be enough of it to prescribe prophylactically so people with 'flu will have to be tested for the type A strain before receiving it. It will be impossible to begin preparing a vaccine until the pandemic strain has revealed itself and then it will probably take in the region of six months. With modern air travel a pandemic could disseminate itself around the world in days.
Respirators and protective equipment are available in small quantities but in the presence of a highly infectious agent it may be necessary to protect oneself in such places as the hospital dining room. One cannot eat or drink with a respirator on! To take it off in order to feed oneself may negate putting it on in the first place.
A cuffed infant face mask (1512 from Intersurgical) fits well over the adult nose and it is fairly easy to achieve a good seal. One's eyes will need protecting and so goggles are necessary. I was able to trim the nasal flanges of a pair of Standard Safety Goggles from B&Q with a sharp kitchen knife and glue an infant mask in place using an electric glue gun. I sealed the gaps with silicone sealant. Into the mask plugs an anaesthetic circuit filter. I chose 1644 because it offers the least resistance to breathing. It was comfortable to wear and a single strap held everything in place. (See picture)
It would be necessary to only breathe out when one's mouth was open for eating, drinking or talking but this discipline was fairly easy to learn. The presence of a pandemic would concentrate the mind.
Associate Specialist in Anaesthesia
Scarborough General Hospital, Woodlands Drive, Scarborough YO12 6QL
Competing interests: No competing interests
Coulombier D & Ekdahl K tell us that, although it is hard to
assess precisely the risk of a pandemic, a pandemic will occur in the
future. They say that Europe is very vulnerable and, if a quarter or more
of the population are affected, then vital functions, such as food and
fuel, will be severely threatened .
They make a one-sentence reference to the SARS epidemic of 2003.
They tell us that Europe produces more influenza vaccine than any
other continent, but that there will be a shortage of vaccine in a
pandemic. We are told that anti-virals would play some part in prevention
because they are effective in the early treatment of influenza.
Coulombier & Ekdahl tell the ordinary person, all too briefly,
what they can do under "non-medical interventions", such as improved
personal hygiene, individuals isolating themselves early on and the
cancellation of mass events.
In the whole of their article, there is absolutely no mention of the
use of face masks, even under their vague "improved personal hygiene".
The UK's Chief Medical Officer writes to all doctors in England a
short article entitled "Preparing for Pandemic Influenza" Nowhere in the
nation's preparation are face masks mentioned!
This silence about face-masks is astonishing! It is astonishing in
the light of the published experience of the SARS epidemic.
The Lancet published the results of a survey of hospital staff
exposed to 11 SARS patients over a two week period . None of the 69
staff who had used either a surgical mask or the N95 mask and who had
taken the other measures used by all staff, contracted the virus.
Of the 13 staff, who did become infected, none of them used anything
more than a paper mask, even though they had washed their hands and done
all the "improved personal hygiene" referred to by Coulombier &
The chief microbiologist in this study from Hong Kong, Professor WH
Seto, concluded that wearing a surgical or N95 mask can give a person,
dealing with SARS patients in hospital, up to 13 times more protection
than not wearing one .
Seto told New Scientist that "masks seem essential for protection"
Whilst members of the public would have difficulty in obtaining
surgical masks during a pandemic, they can purchase the N95 masks before
the pandemic starts. They cost about £2 each.
Why would anyone want to have an N95 mask in the house?
Firstly, they are effective in protecting against influenza viruses
as shown in the SARS epidemic, where those people working in a virus super
-charged atomosphere did not get infected if they were wearing an N95 or
equivalent surgical mask.
Seto says that masks, designed to block airborne particles, will
protect the face from droplets coughed out by infected people. His survey
findings fit well with droplet transmission, which is generated at face
Someone may say that the N95 mask will only filter out particles
larger than 0.3 microns (300 nanometres) and that viruses are much smaller
than this. The SARS virus ranges in size between 80-160 nanometres.
However, the viruses will be clumped together in sputem and phlegm,
and covered in mucus and water.
Secondly, there will not be enough anti-virals for everyone.
Thirdly, there will be a dangerous delay before the vaccine becomes
available in bulk.
Fourthly, it is something which the helpless man, woman and child can
do to protect themselves effectively. And that does make you feel much
So why do Coulombier & Ekdahl, of the prestigious Europe Centre
for Disease Prevention & Control, not even mention face-masks?
Why does the Chief Medical Officer in England fail to tell doctors
about the benefits of face-masks for their patients and, indeed, for
Perhaps the reasoning goes that this is a medical problem and must be
left to the experts supplying anti-virals and vaccines, because there is
nothing that the simple public can do.
It is fascinating how published information, such as the protective
benefits of face-masks in the SARS epidemic, can be rendered pointless in
the hour of greatest need. So what is the point of publishing medical
When a "John Snow pump handle" solution is there from reading an
article in the Lancet, what is the point of medical publishing if tens of
thousands are killed by the virus and tens of thousands are left damaged?
When the broadcast recommendation to use an N95 mask could have been
given, and thousands upon thousands of personal, national and business
economies saved, all from the reading of an article in the Lancet, what is
the point of medical publishing?
1. H5N1 Influenza and the Implications for Europe, Coulombier D &
Ekdahl K, BMJ 2005; 331: 413-414 (20 August).
2. Preparing for Pandemic Influenza, CMO Update, Issue 42, p1-2, Summer
3. The Lancet Vol 361, p 1520, 203.
4. Face Masks are Best Protection Against SARS, New Scientist 15 March
Competing interests: No competing interests