Conflicts of interest and pandemic flu

We have to agree with the Editor in Chief when she states:

“The big question is what to do about the conflicts.
On the basis of our own investigation and those of others, the answer is
now inescapable. As Barbara Mintzes says in Cohen and Carter’s report, "No
one should be on a committee developing guidelines if they have links to
companies that either produce a product—vaccine or drug—or a medical
device or test for a disease." The same, and more, must apply to
committees making major decisions on public health.

Where entirely independent experts are hard to find, experts who are
involved with industry could be consulted but should be excluded from
decision making.”
(BMJ 2010;340:c2947 Fiona Godlee, editor in chief)

Has the BMJ editorial board considered the possibility of having
commercial conflict of interest statements include the amounts of
remuneration that someone has been paid historically for acting on behalf
of a third party with a vested interest, and how much they will receive
for work under consideration?

Furthermore, given the BMJ’s concern about commercial conflict of
interest would it not make sense to move towards excluding those
conflicted relations from the peer review process as well? Where
independent experts can not be found, it could be stated explicitly in the
review process and with publication. Moving towards a review system that
excludes peer-reviewers with commercial vested interests is a logical
extension of the position that Godlee advocates in her editorial and would
better serve the public health.

Competing interests:
None declared

I was interested to note the words taken by Fiona Godlee from the
Cohen and Carter report: "No one should be on a committee developing
guidelines if they have links to companies that either produce a
product—vaccine or drug—or a medical device or test for a disease."(1). A
topic of much debate recently has been NICE's thromboembolism
guidelines(2). Those with conflicts of interest on the NICE panel include
Nandam Gautam (Bristol Myers-Squibb), Aroon Hingorani (Pfizer), Beverley
Hunt (Sanofi Aventis, Bayer and Boehringer), Nigel Langford (Sanofi
Aventis), Simon Noble (Leo Pharma, Boerhinger Ingelheim, Sanofi Aventis),
Annie Young (GlaxoSmithKline), Simon Frostick (Boehringer Ingelheim,
Bayer), David Warwick (Boerhinger Ingelheim, Sanofi Aventis) and Nick
Welch (Boerhinger Ingelheim). Cosequently I wonder if these guidelines
are worth the paper they are written on?

1. Godlee F. Conflicts of interest and pandemic flu. BMJ
2010;340:c2947
2. Venous thromboembolism: reducing the risk of venous
thromboembolism (deep vein thrombosis and pulmonary embolism)in patients
admitted to hospital. NICE. January 2010.

Competing interests:
None declared

Sir

I commend on the investigative approach of your journal.

At the start of the "swine flu pandemic" in Hong Kong, which
responded by keeping tourists under quarantine in a hotel, I was asked by
reporters about the future of this threat. I reassured them that this was
a false alarm, and that it was nothing like SARS, which gave Hong Kong a
harsh lesson in 2003 (and for which I criticized the public health
officials harshly for their slow action). My complacent response was based
on two observations: First, mortality rate was not high. (There were a
number of deceased where the virus was isolated, but that did not mean
they died of H1N1 influenza.) Secondly, infectivity was not high. I found
it hard to justify the WHO raising the alarm to pandemic level. However, I
told the reporters that the health officials will respond exactly
according to what WHO recommended. This was a case I called the butt
commanding the brain (a Cantonese saying which means one's decision
depends on the post one is holding, not on rational thinking). If I were
the health secretary or director, I would have nothing to gain if I insist
on my own judgement, even though it was based on sound epidemiological
evidence. On the contrary, if I did insist on my own view, and the
epidemic worsened, my head would roll. After all, who could criticize me
if I, like health officials all over the world, faithfully did what WHO
recommended?

So, Hong Kong responded by spending millions on vaccination
and stockpiling of oseltamivir. (The latter recommendation, advocated as a
preventive measure against the highly lethal avian flu, was especially
open to questioning, since most cases of avian flu did not respond to the
drug.) The vaccination programme ended with a few cases of Guillain Barre
syndrome that no one could rule out the vaccine as a cause. The result -
about 90% of the vaccines were not used. Even for relatively affluent Hong
Kong, the opportunity cost is substantial. Yet, the health authority said
this was insurance premium worthy of paying. No lesson was learnt.

TW Wong

School of Public Health and Primary Care

The Chinese University of Hong Kong

Competing interests:
None declared