Bird flu and transparency

Last week's outbreak of H5N1 avian flu in turkeys in England brings the threat of pandemic flu psychologically if not actually closer to western Europe. And although WHO and others are rightly playing down the risks of a pandemic, they are also rightly preparing for one. But what are the right local and global priorities?

Clinical guidance is the easy bit. New guidelines published in the BMJ's sister journal Thorax and summarised in a BMJ editorial this week (doi: 10.1136/bmj.39101.628715.80) advise rapid diagnosis, prompt administration of antivirals, and readiness to give antibiotics if symptoms worsen.

Far harder will be to prepare—psychologically and actually—for making these clinical decisions within what are euphemistically termed “limited resources.” As our editorialists say, this will require triage and difficult ethical decisions. The UK has established a committee on ethical aspects of pandemic influenza (CEAPI), which should soon be offering its own guidance.

And what about prevention? In addition to antivirals, the Suffolk poultry workers are being offered seasonal flu vaccine (doi: 10.1136/bmj.39118.669375.DB). This is so that, even in the highly unlikely event that they were infected with H5N1, the virus would not mix with seasonal flu virus and acquire the ability to pass easily from human to human. Such a mixing is, of course, most likely to happen in Asia, where far more people are in close contact with birds. Enlightened self interest—or as Michael T Osterholm put it when addressing the world's flu experts in America last week, “saving our own tails” (doi: 10.1136/bmj.39118.367523.DB)—suggests we should be doing more than stockpiling marginally effective antivirals for our own use. As proposed in the BMJ last year (2006;332:786, doi:10.1136/bmj.332.7544.786), for its own sake the rich world should be doing more to help the poor nations in Asia to strengthen their health systems so they can respond to this and other threats to health.

And if stockpiling does make sense, are we right to plump solely for oseltamivir? In this week's BMJ Sotiris Tsiodras and colleagues say no (doi: 10.1136/bmj.39105.428981.BE). They ask how much the exclusive preference for oseltamivir is due to the lack of incentive for drug companies to evaluate the older and cheaper amantidine. We have previously reported on the role of opinion leaders paid by industry to promote oseltamivir as the single global choice (BMJ 2005;331:127, doi: 10.1136/bmj.331.7527.1277).

This seems to underline again the importance of transparency about where opinion comes from. As its contribution the BMJ is introducing, in addition to conflict of interest statements, new statements of “provenance and peer review” for opinion and comment articles in the journal (see http://resources.bmj.com/bmj/authors/editorial-policies/transparency-policy). The statements describe whether an article was commissioned by us or sent in unsolicited by the authors, and whether or not it was externally peer reviewed. We will roll them out across the journal over the next few weeks, starting this week in editorials. Usually they will be brief but occasionally they will tell a story, as with this week's editorial on drug treatments for neovascular acute macular degeneration (doi: 10.1136/bmj.39100.460671.BE), the idea for which came after one of the authors was invited but declined to write an editorial for Pfizer about its vascular endothelial growth factor inhibitor drug. Are you glad to have been told this?