The UK’s public health response to covid-19
BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1932 (Published 15 May 2020) Cite this as: BMJ 2020;369:m1932Read our latest coverage of the coronavirus pandemic
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Dear Editor
Allan Cunningham writes:
"Other geographic correlations might be useful, but it would be far better to compare Covid-19 disease/death frequencies in groups who get flu shots with frequencies in groups who don’t. Randomized trials would be ideal, but unbiased observational studies might work—something along the lines of the vaccine effectiveness studies done every year for influenza."
As we head towards winter in in the northern hemisphere, and the Britsh government extends its flu vaccination campaign over previous years, it woud be interesting to know what steps it has taken to look into this concern?
Allan Cunnningham, 'Flu shots and Covid-19 mortality correlation', 28 July 2020, https://www.bmj.com/content/369/bmj.m1932/rr-24
Competing interests: AgeofAutism.com, an on-line daily journal, concerns itself with the potential environmental sources for the proliferation of autism, neurological impairment, immune dysfunction and chronic disease. I receive no payment as UK Editor
I thank Davide Radice for his comments (BMJ rr 7/27/20) but they left me a little confused. I did not refer to population sizes, as he states. I referred to rates: the rates of flu shot uptake in the elderly and Covid-19 death rates. However, prompted by Mr. Radice’s letter I updated the correlation with data for July 27, 2020. (www.worldometers.info/coronavirus) For 20 European countries r = 0.742, P<<0.001. (The regression equation is: y=8.271x—90.740, where x is the % uptake of influenza vaccine in the elderly and y is the number of Covid-19 deaths per million. Correlation was performed on a Casio fx-300MS scientific calculator) r-squared = 0.55, signifying that 55% of the variation in Covid-19 death rates is explained by variation in flu shot uptake. The slope of the regression line is 8.271, indicating that for every 10% increase in flu shot uptake there is an increase of about 83 Covid-19 deaths per million.
Other geographic correlations might be useful, but it would be far better to compare Covid-19 disease/death frequencies in groups who get flu shots with frequencies in groups who don’t. Randomized trials would be ideal, but unbiased observational studies might work—something along the lines of the vaccine effectiveness studies done every year for influenza.
Overall, the lifesaving value of seasonal influenza vaccines is uncertain. This fact was recently highlighted by a study that looked at mortality in the elderly over a 14-year period. (Anderson et al, Ann Intern Med 2020;172:445) Table 2 indicates that influenza vaccine was associated with an 8.9% increase in all-cause mortality in elderly men (VE—8.9%, CI –19.6% to 1.8%), and a 26.5% increase in pneumonia-influenza mortality (VE –26.5%, CI –56.1% to 3.0%)
ALLAN S. CUNNINGHAM 28 July 2020
Competing interests: No competing interests
Dear Editor
I am not sure that David Radice is correct when he claims that there is no correlation between overall influenza vaccination rates and mortality in people aged 65 and over. He does not explain his view beyond a bald statement of view.
What is the hypothesis being tested?
For example, children are vaccinated against 'flu not for their individual benefit but to interrupt natural infection and so reduce 'flu infections in older adults.
Accordingly, surely it must be right that we must compare overall vaccination rates in all ages with mortality in the elderly if one is to test the hypothesis of an association.
Is not the hypothesis to be tested is that immunity in the elderly is compromised by interrupting natural infection in the overall population?
Hence, surely one must compare overall vaccination rates with mortality in the elderly? I should be pleased to be corrected if I am thought to be wrong.
Competing interests: No competing interests
Dear Editor,
I read the rapid response of Allan S. Cunningham [1] who proposes a sort of correlation between the death rates of people aged 65+ with the percent coverage of vaccinated against flu, in EU countries. Given his data and with a little extra effort (and assuming a linear relationship between the two quantities), the correlation coefficient is r-square = 0.53 (p = 0.0003), that seems indeed impressive.
However, referring to the total population size instead of the size of the popluation 65+ is a mistake: if you want to see if a correlation between the death rate and the vaccination rate that exists for people aged 65+, you must compute the ratio between detah counts for people aged 65+ and the size of the population aged 65+.
Taking, for example, the World Bank estimates for the size of the population aged 65+ for each EU country included in Allan Cunningham's reply, it's easy to see that there is no correlation at all between the flu vaccination coverage and the corrected (age adjusted) mortality rate (r-square = 0.003, p = 0.82).
[1] Allan S Cunningham, ‘A whimsical suggestion: correlate influenza vaccine uptake with Covid-19 frequency’, 21 May 2020, https://www.bmj.com/content/369/bmj.m1932/rr-15
Competing interests: No competing interests
Dear Editor,
In Scally et al.’s [1] editorial entitled “The UK’s public health response to covid-19” it’s argued that “politicians and their advisers cannot hide behind science to avoid responsibility for making difficult decisions in a global crisis or merely repeat that they are following the science”. However, the lack of transparency and in several instances during the pandemic, it has been highlighted that the UK Government haven’t “followed the science” to the mantra that the public have been led to believe.
In response to the coronavirus (COVID-19) pandemic, it was encouraging to hear that the UK Government were “following the Science” in reference to the evidence and recommendations put forward by the Scientific Advisory Group for Emergencies (SAGE) whose role is to provide timely and coordinated scientific and technical advice. [2]
The continuous reference to “following the science” by UK Government ministers throughout the COVID-19 pandemic, has led to public faith that the very best scientific evidence and recommendations are, as the statement suggests being followed. However, the misalignment between Government actions during the pandemic and the scientific advice, resulted in the formation of the Independent Scientific Advisory Group, and in doing so, allowed for clarity and confirmation that, in fact, the UK Government are not always “following the science”.
The Independent SAGE have, on several occasions, released statements and appeared in the media informing that there is disagreement between the scientific evidence and the decisions and actions of the Government, and thus, the purported lengths that the Government are following scientific advice is an overstatement and is misleading the public. Whether it is the re-opening of schools or the delayed move to lockdown, [3] the relationship between UK Government and the SAGE is much more reflective of the UK Government’s Chancellor of the Exchequer Rishi Sunak’s stance that scientists were providing advice, but ministers were making decisions – and that these decisions weren’t necessarily in alignment with scientific evidence [4]:
"I think Chris Whitty and Patrick Vallance throughout all of this have provided advice to ministers and ultimately it's for ministers, whether it's me, the prime minister, health secretary, and others, we are the people who are elected to make decisions in this country"
It would thus, be more accurate of the Government to refrain from widely using the mantra that they are “following the science” and consequently misleading the public as this is less frequent than currently portrayed. The continued and consistent use by UK Government ministers is likely to lead to a false belief amongst the public that scientific evidence is shaping the UK Government’s COVID-19 pandemic response.
References
1. Scaly G, Jacobson B, Abbasi K. The UK’s public health response to covid-19: too little too late, too flawed. BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1932 (Published 15 May 2020) BMJ 2020;369:m1932 https://www.bmj.com/content/369/bmj.m1932 (accessed June 28, 2020)
2. UK Government. Scientific Advisory Group for Emergencies (SAGE): Coronavirus (COVID-19) response. 2020. https://www.gov.uk/government/groups/scientific-advisory-group-for-emerg... [Last accessed 14th June 2020].
3. Independent Scientific Advisory Group on Emergencies. When Should School reopen? 2020. https://www.independentsage.org/wp-content/uploads/2020/06/Independent-S... [Last accessed 14th June 2020].
4. Stone J. Coronavirus: Government could overrule scientific advisers and relax two-metre distancing rule, chancellor says. The Telegraph. 2020. https://www.independent.co.uk/news/uk/politics/coronavirus-two-metre-2-m... [Last accessed 14th June 2020].
Competing interests: No competing interests
Dear Editor
The other question that has not been satisfactorily answered is why doctors - who undertake a hippocratic oath did not resist or protest at discharging people early to care homes- knowing or at least understanding they could unleash deadly infections there.
When doctors do not fee free to challenge their instructions - and question faulty flawed guidance we really have lost our way as a service to protect the public’s health and well-being.
Competing interests: No competing interests
Dear Editor
This editorial identifies where the UK plan for COVID that was backed by science went wrong, with ideas on what now needs to be done? (1), which can be extended globally.
The expectation of science is to protect us and make a better world – how it is used is another story. Following the science should be a good thing, until it’s not. As identified, science and public health have been underdeveloped, misunderstood, misused and not used in context.
Science is simple - knowledge that is testable, usable to predict, and refutable, while its use or claims of its use is complex - see - Science evidence and the use of the word scientific, Lancet Letter (2) https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)73141-X/fulltext
Science and public health have not failed us in this pandemic – how they are used and managed have. The editorial points out numerous instances, with recommendations for fixing this. In particular, politics, which is very complex, weaves itself into health and public health, making these even more complex.
A complexity thinking can help us understand and use science in context to make a better world (3). The reality is that everything that happened was in the context of the politics, economics, society, etc and is part of the interaction of science and society. We need to FACE this reality and use a complexity thinking to make it better, with Feedback, Adaptation, Change, and Emergence of better, which sometimes works.
A complexity thinking would expand the narrow scientific view beyond the modellers and epidemiologists as decried, to include people who have experience taking the science to society, in an open manner as also identified, with debate and discussion to allow for change and adaptation as necessary. A similar caution re following the science exists with complexity, with contention that it was misapplied by a UK Govt senior adviser, reinforcing the need for open discussion (4).
The editorial argues that “The response to COVID-19 is not about flattening epidemic curves, modeling or epidemiology. It is about protecting lives and communities most obviously at risk in our unequal society. …requires a strong and credible public health of community at the heart its response…a UK govt that prioritizes the health and well being of the public…,” which brings me back to how science is used as another story.
“Complexity: The science for medicine and the human story” Lancet Letter (5) , https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60512-0/fulltext
suggests that “Medicine and its underlying science not only change, but lie in the eye of the beholder. To some they mean absolute truth and validity, to others uncertainty and the contextual nature of reality. This makes medicine a human story, with an ever-changing complex, dynamic, intertwined art and science—and chaos and complexity its science for the 21st century.”
This should then make Complexity the science for Covid, public health and the human story.
1. Scaly G, Jacobson B, Abbasi K. The UK’s public health response to covid-19: too little too late, too flawed.
BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1932 (Published 15 May 2020) BMJ 2020;369:m1932 https://www.bmj.com/content/369/bmj.m1932 (accessed May 20, 2020)
2. Rambihar VS. Science evidence and the use of the word scientific
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)73141-X/fulltext
(accessed May 20, 2020). Lancet 2000 May 13;355(9216):1730. doi: 10.1016/s0140-6736(05)73141-x. PMID 10905277
3. Rambihar VS, Rambihar SP, Rambihar VS Jr. Tsunami Chaos and Global Heart: using complexity science to rethink and make a better world. 2005. Vashna Publications. Toronto, Canada. http://femmefractal.com/FinalwebTsunamiBK12207.pdf (accessed April 11, 2020).
4. Taleb N, Bar-Yam Y. The Guardian Opinion. Wed 25 March 2020. The UK's coronavirus policy may sound scientific. It isn't. https://www.theguardian.com/commentisfree/2020/mar/25/uk-coronavirus-pol... (accessed May 22 2020).
5. Rambihar Vivian, Rambihar Vanessa. Complexity: the science for medicine and the human story. Corespondence: Lancet Vol 375, Issue 9721, p 1162, April 03, 2010 DOI:https:/doi.org/10.1016/S0140-6736(10)60512-0 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60512-0/fulltext
(accessed May 20, 2020).
Competing interests: No competing interests
Dear Editor
Thanks as ever to Allan Cunningham [1], but I am not sure we know that his suggestion is whimsical. If researchers have previously thought there was value in researching the impact of flu vaccine on other infectious diseases (and found evidence for it) it could not be more important to do so now before the roll out of flu vaccine in the autumn, possibly alongside a COVID-19 vaccine. Would it not be merely sensible rather than whimsical to research the flu vaccine status of those who have been seriously sick - like the Prime Minister - from the SARS-CoV-2 virus, as well as those who have died?
[1] Allan S Cunningham, ‘A whimsical suggestion: correlate influenza vaccine uptake with Covid-19 frequency’, 21 May 2020, https://www.bmj.com/content/369/bmj.m1932/rr-15
Competing interests: AgeofAutism.com, an on-line daily journal, concerns itself with the potential environmental sources for the proliferation of autism, neurological impairment, immune dysfunction and chronic disease. I receive no payment as UK Editor
Reference has been made to the possibility that influenza vaccines increase the risk of coronavirus infections (Wolff, Vaccine 2020;38:350) and that this might be relevant to Covid-19 infections (www.bmj.com/content/368/bmj.m1089/rr-10).
Furthermore, students of the subject have been perplexed about the wide geographic variation in the frequency and death rates of Covid-19.
I suggest that we look at influenza vaccine uptake in the elderly and Covid-19 death rates in European countries, using existing data. One source for vaccine data: OECD (2020), Influenza vaccination rates (indicator) doi:10.1787/e452582-e (Accessed on 21 May 2020). This lists, by country, the % of the population aged 65+ for 2018 or the latest available year. For Covid-19 death rates by country as of 21 May 2020: www.worldometers.info/coronavirus.
% INFLUENZA VACCINATIONS IN THE ELDERLY/COVID-19 DEATHRATES PER MILLION
Czech Republic 20.3/28 Lithuania 13.4/22
Denmark 52.0/97 Luxembourg 37.6/174
Estonia 4.8/48 Netherlands 64.0/337
Finland 48.4/55 Norway 34.4/43
France 49.7/431 Portugal 60.8/125
Germany 34.8/99 Slovak Republic 13.0/5
Hungary 26.8/49 Slovenia 11.8/51
Ireland 57.6/319 Spain 53.7/596
Italy 52.7/535 Sweden 49.4/384
Latvia 7.7/12 United Kingdom 72.6/531
To see if there is an association between the two factors find the correlation coefficient using a small hand calculator. Otherwise, make a scatterplot on a piece of graph paper…….Have fun!
ALLAN S. CUNNINGHAM 21 May 2020
Competing interests: No competing interests
Re: The UK’s public health response to covid-19
Dear Editor
Islamic Instructions to Avoid Coronavirus/Covid-19 among British Muslims
Please allow me to explain the Muslim culture and the Muslim beliefs and practices in order to avoid most of the Coronavirus infection among our own Muslim community.
This Islamic contribution for PUBLIC HEALTH will, without any doubt, reduce hugely the number of cases of infection by Coronavirus and Covid-19 among our 3 million British MUSLIM citizens: among our own Arab/Asian/African and white Muslim community if they did know about these Islamic instructions and try to practise them.
A practising Muslim believer, male or female, is the one who tries to implement in his/her daily life the Verses in the final Holy Book: Al Quran and the Sayings and practices/Sunnah of the final Prophet Muhammad (peace be upon him).
It was amazing to discover lately the many hygienic and healthy measures practised and prescribed by the Prophet before which, if implemented today, will avoid us a large number of Coronavirus infections and Covid-19 and other droplet infections.
Unfortunately, the WHO have failed to address well the dangerous spots on the face and human body which usually have and harbour the Coronavirus infection/ and many other infections.
There was a lot of talk and advice on the need to have repeated HAND WASHING by the WHO and by the Health Dept in the UK and by doctors in every country. The latest advice we received: Wash your hands 6-10 times/day!
Interestingly we discovered this Islamic religious advice which was stated more than 1400 years ago to wash our hands at least 25-30 times/day as a religious duty and to do it all the time and in all places whether there is a plague/epidemic or not.
If you allow me to explain more:
We all know that the hands are considered in the science of bacteriology today as the biggest source of many infections, viruses and bacteria, and to spread them around!
The Islamic instructions on hand washing repeatedly are found to be very interesting:
A practising Muslim should wash his/her hands:
First: before doing each of the 5 obligatory daily prayers: 3 times for each hand / 15 times/day in so called ABLUTION (WUDU).
At least 25-30 times, a practising Muslim does wash his/her hands during the day for ablution and for other situations as we will explain later;
Not only the hands are washed befoe each prayer, but also so many other organ spots which can harbour the Coronavirus or have a lot of viruses and bacteria.
-THE MOUTH 3 times/gargling
-THE NOSE 3 times
-THE FACE including the EYES 3 times
All of these are important sources toi give us infections and the Coronavirus.
The mouth, the nose and the face/eyes were unfortunately neglected by WHO in its advice to be washed and by doctors and by all departments of health in almost all countries!
We Muslims have also to do this extra washing before each prayer:
-THE 2 ARMS 3 times each
-RUBBING WITH WATER : THE FRONT OF THE HAIR OF THE HEAD AND THE 2 EARS
-FINALLY: THE 2 FEET 3 times each.
More Prescribed Hand washing:
Every practising Muslim is requested to wash his/her hands on these occasions too:
-When one wakes up
-After coming out of the toilet
-Before eating
-After eating
-If one touches his/her private/genitals
-Or when touching a dead body
-Or if the hand touches any dirt or unhygienic item.
-And to wash hands 7 times (one by sand) if one touches or has been touched by a dog especially from his/her mouth or from the anal area.
Also: the final Prophet Muhammad (peace be upon him) recommended when doing the ablution and before each prayer to BRUSH OUR TEETH (Miswak) too (5 times/day).
Nails should also be cut frequentky and regularly as advised by the Prophet.
No doubt after the implementation of all these strict repeated obligatory hygienic healthy measures of comprehensive hygiene and cleanliness (washing and flushing), we believe that almost all viruses and bacteria including the Coronavirus will be avoided or washed aay, thus avoiding a lot of infections!
OTHER PRESCRIBED HYGIENIC HEALTHY MEASURES BY THE PROPHET:
WHEN SNEEZING
"Another protective hygienic measure done by the prophet before and ordered us to do it :
Whenever He sneezed, he would cover his mouth with his hand or a piece of cloth,
Or sneeze into the elbow
WHEN COUGHING
Similar measures to implement when COUGHING TOO.
WHEN YAWNING
The prophet also used to cover his mouth when yawning.
AVOIDING CROSS INFECTION
The Prophet Muhammad (peace be upon him) has ordered us in a Hadith/saying
"NO SICK PERSON (WITH INFECTION) SHOULD MOVE AND BE NEXT TO A HEALTHY ONE!"
(social distancing)
Great prophetic advice to avoid cross infection or to avoid spreading the infection around...
Any Muslim with any infectious disease like: Cold Flu/Influenza and Coronavirus...
Should avoid being next to a healthy person especially in the mosques: Friday prayer/ at 5 daily congregation prayers in the mosque...
WHEN THERE IS A PLAGUE/INFECTITIOUS DISEASE IN A LAND
The Prophet ﷺ said, "If you hear about it (the plague) in a land that you are in, DO NOT LEAVE IT, and if you hear about a plague in a certain land, DO NOT ENTER THE LAND"
I like to recommend all these hygienic and healthy measures to all British Muslims in the UK and abroad in order to avoid most of the infections by Coronavirus and other droplet infections too like the Flu, Diphtheria, Meningitis.... and to reduce well the rate of Covid-19 among all of us.
Unfortunately, many Muslims are not aware of all these Islamic hygienic healthy measures in order to avoid Coronavirus and Covid -19 and other droplet infections. Also , many Muslims, unfortunately, do not practise it !
NB: We have got all the Islamic references regarding each hygienic or health measure which were prescribed by the Prophet before.
DR A MAJID KATME (MBBCh, DPM)
Ex-President: Islamic Medical Association.
TV/RADIO broadcaster
Competing interests: No competing interests