Influenza: questions and answers
BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d190 (Published 12 January 2011) Cite this as: BMJ 2011;342:d190All rapid responses
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Apart from extra money, there is already enough "encouragement" for
GPs to vaccinate.
http://www.bma.org.uk/health_promotion_ethics/influenza/panflugp/index.jsp
However, the real question is whether it is true that the flu vaccine
probably has no benefit.
http://www.bmj.com/content/342/bmj.d212.full/reply#bmj_el_248059
It is only natural that nouns like HPA, Department of Health, Royal
Colleges, Public Health etc, cannot talk and were individuals afraid to
raise this with Adrian O'Dowd?
Only people in the know, that work under the umbrella of these nouns
can make an honest attempt to answer the question whether flu vaccine
contributes to the health of the individual patient. This calls for a
Brian Deer approach. Or will this remain an other question?
Dr. Goodman is quoted in the NY Times with reference to an article he
co-autored in the 4 Jan 2011 issue of Annals of Internal Medicine , that
"either everyone thinks their study is really unique (when others thought
it wasn't), or they want to unjustifiably claim originality, or they just
don't know how or want to look."
http://www.nytimes.com/2011/01/18/health/research/18cite.html?_r=2&ref=s...
Competing interests: No competing interests
As a front-line GP, there is always the need to balance several
(often competing) pressures:
What a patient wants us to do, What we can do that will good for the
patient, What NICE/DoH/drug companies think we should do, What we (the
NHS) can afford to do.
Managing both pandemic and seasonal influenza have been shining
examples of this juggling act.
Adrian O'Dowd's article has been very useful in jogging memories the
effect of a bad flu season on mortality. Unfortunately, it lacks any
critique of the advice for liberal use of anti-virals.
Thankfully, we can turn to the Cochrane databse for help on this
issue. We would urge anyone who either recommends or presribes anti-viral
therapy for flu to first read the updated 2010 cochrane review on this
topic:
"We do not recommend NIs for routine use in seasonal influenza except
for life-threatening illness, and in circumstances where they used as an
adjunct to other public health measures. We urge caution in the
administration of NIs until some of the problems such as psychotropic
effects and resistance have been clarified. Updating this Cochrane review
has increased uncertainty about the safety of NIs, their capacity to
interrupt viral transmission, or to affect complications rates."
http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD001265/fra...
Competing interests: No competing interests
Typically, most complications, admissions, and deaths from influenza
occur in older people. But many people over the age of 65 appear to have
prior immunity to influenza pH1N1, so they are relatively protected from
this strain. This may explain the impression that many seem to have had
that this strain of flu is "less serious" than other strains.
In order to compare the morbidity, admission, and mortality rates for
this strain of flu with others, we need be able to compare age-adjusted
rates. How do the case-fatality, morbidity, and admission rates compare
for different age groups?
Until we can answer this question we really cannot say whether pH1N1
influenza is more or less virulent than previously circulating strains.
Competing interests: No competing interests
Influenza and Intensive Care
We read with interest the report by O'Dowd (BMJ 2011; 342: 134-135)
describing the UK and NHS response to the heaviest winter influenza surge
since 1999. As he states, between 5th September 2010 (week 36) and 5th
January (week1) 50 deaths associated with influenza have been reported
across the UK. However, he does not mention the major impact the surge
has had upon intensive care units (ICUs), which responded to the crises by
rapidly increasing capacity through staff working additional hours and by
adapting other facilities such as postoperative recovery units. A five-fold increase (approximately 5-25 beds) was achieved in capacity for extra
corporeal membrane oxygenation for the most severely affected cases (1).
Across the UK more than 1000 critically ill adult patient with influenza
have been admitted during the epidemic. In the NHS London region on
January 14th, of 14331 acute beds potentially available at 0900 only 665
(approximately 5%) were in adult critical care; 78(11.7%) of which were
occupied by patients with confirmed or suspected cases of influenza, down
from a peak of approximately 140 (22%) on 5th January.
This should be seen in the setting of overall ICU provision for
England. In 2010 a total of 3622 general and specialist adult ICU beds
were available (3.39% of the 106,731 acute hospital beds). Of these, only
1989 were Level 3 beds providing invasive mechanical ventilatory support
(1.86% of acute hospital beds). Moreover, only 1132 ICU beds were
available for general and emergency care: approximately 600 are allocated
to cardiothoracic surgery, and 400 to liver, neurological, spinal injuries
and burns units. Others have estimated an ICU bed rate for the UK as a
whole of 3.5 ICU beds per 100,000 population; by far the lowest of 7
developed economies in Europe and approximately 15% and 25% of those
available in the USA and Canada respectively (2).
Not surprisingly, international surveys have shown that 65% of UK
intensive care specialists report ICU admission commonly to be limited by
bed availability (3). Despite severely limited resources and massively
increased demand the intensive care community has managed to sustain a
clinically excellent service, as witnessed by the relatively low mortality
reported by O'Dowd, but at the expense of other clinical services
dependent upon a comparatively low level of overall provision.
Timothy Evans (Vice Dean) and Julian Bion (Dean) Faculty of Intensive
Care Medicine; and Bob Winter (President, Intensive Care Society).
References:
1. Noah M, Peek G, Harvey C et al. Coordinated response for ECMO. BMJ
2010 341: c7391.
2. Adhikari NK, Fowler RA, Bhagwanjee S, Rubenfeld GD. Critical care and
the global burden of critical illness in adults. Lancet 2010; 376: 1339-
1446.
3. Vincent JL. Forgoing life support in western European intensive care
units: The results of an ethical questionnaire. Crit Care Med 1999; 27:
1626-1633
Competing interests: No competing interests