An iatrogenic pandemic of panic
BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7544.786 (Published 30 March 2006) Cite this as: BMJ 2006;332:786All rapid responses
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Bonneux and Van Damme comment on ‘wasteful investments in large
stocks of drugs of no clear use’ in pandemic flu1. I agree oseltamivir
(Tamiflu) use needs further thought.
PCTs have been asked to provide ‘safe storage and rapid access to
antiviral medicines – without adding to pressures on health systems,
encouraging spread of infection or allowing multiple doses to be obtained
against one case’2.
Getting these logistics right is challenging. Supplies are enough for
only 25% and some wanting oseltamivir may not get it. Patients will need
vetting to ensure they are ill enough, early enough. If done at selected
centres, ill patients risk spreading infection. If a representative is
seen, there are issues around vetting for symptom severity and duration.
If teams do home visits, they may be at personal risk from carrying
oseltamivir and find it difficult to deny the drug. With uncertain
supplies of protective equipment, we cannot currently be sure those
assessing people for oseltamivir can be made to feel safe. To avoid
duplicate supply requires a record system. If enough health care workers
and volunteers for oseltamivir vetting and distribution are found, that
reduces capacity elsewhere.
If modellers advise the local pandemic will be sharper than
originally thought, and that it is better if oseltamivir is taken within
12, rather than 48, hours of symptom onset, there will be even greater
pressure for a high capacity delivery system around the clock. If this
does not work perfectly, some will be aggrieved afterwards, probably
including some of the bereaved. Oseltamivir has been presented as a life
saver, and the public will see it as such.
Planners need to take care that oseltamivir does not skew local
planning inappropriately, with distraction from other measures such as
strengthening general resilience and specifics like hand washing3.
1. Bonneux L, Van Damme W. An iatrogenic pandemic of panic BMJ
2006;332;786-788
2. DH UK operational framework for stockpiling, distributing and using
antiviral medicines in the event of pandemic influenza. On
www.dh.gov.uk/assetRoot/04/11/96/10/04119610.pdf (accessed 7 Apr 06)
3. Pickles H, Tailor V. Might oseltamivir be a mixed blessing? The
Pharmaceutical Journal; 2006;276;11
Competing interests:
None declared
Competing interests: No competing interests
Thank you for the new perspective of looking at bird flu.
In a pandemic like bird flu, there are surely some problems that are related to
the duty of informing people and managing the information.
Maybe we face these questions:
1- When should we inform people: In my point of view, as soon as we are informed ourselves.
2- How should we inform people?
My answer is, completely and efficiently. Feeling panic is in the nature of information. And such a panic can be of value if being in control.
3- Until when should be continue informing people?
I think we have the duty to share any information with people. It covers the new progress in vaccines and drugs which have been looking promising.
I think the time and money which is being spent on bird flu is really needed. It is true that we have too many other problems in the world, but the virus that is spread by wintering birds to the whole world and is threatening all populations of the world and the economy of almost all countries is worth the extra attention.
Preventive efforts have been done in more at risk countries and have shown and changed the false life styles. Like hen houses which are built over ponds. No need to say those efforts of controlling bird flu have truly slowed the global pandemic.
I think the extra attention of all governments is really needed.
Ada Majd, MD.
Competing interests:
None declared
Competing interests: No competing interests
I enjoyed reading the interesting critique of the current concern
over pandemic flu by Bonneux and Van Damme. Their advice to ensure that
there is adequate bed capacity in the acute sector will be met with hollow
laughter by many of us working at the coal face of the NHS. Our undersized
PFI-funded district general hospital already struggles to cope with
emergency admissions in quieter periods, despite regularly cancelling
elective surgical admissions. It seems clear that we will have to get on
with it in the community, where therapeutic options are limited.
Oseltamivir shortens the duration of the illness by on average one day and
any vaccine will not be ready in time. It was therefore refreshing to read
that some of the traditional core values of medicine still have a part to
play.
Against this background the pundits are encouraging each practice to
draw up plans to deal with the projected health chaos and ensure “business
continuity”. At a time of soaring demand, with a reduced and enfeebled
workforce, I cannot see where the extra capacity will come from. Our only
hope will be to rediscover the sense of vocation and teamwork that has
been squeezed out by the culture of audit and accountability, and all pull
together. We may even be able to enlist the help of recently retired
doctors. Assuming, that is, that they are on the PCT Primary Medical
Performers List, have had a recent appraisal, and are in possession of a
valid PDP approved by the Clinical Governance Lead.
Competing interests:
None declared
Competing interests: No competing interests
Over the last few decades the public health community has lost
numerous opportunities for building and strengthening the overall capacity
of health systems in developing countries, by channeling towards "magic
bullet" solutions, the general public's fears and concerns in face of
public health threats.
,P>The attached article provides a very comprehensive look into the response
to the Avian Flu crisis and formulates recommendations for some very sound
public health responses that are urgently needed, particularly in
developing countries.
In most developing countries, disparities and exclusion of large segments
of society from the most basic health services, health education and basic
sanitation pose the greatest public health threat of all, not only in face
of pandemics, but in face of common and ordinary day to day scenarios.
In order to quickly provide such an authoritative insight for Latin
American countries, currently under great pressure to spend their very
limited resources in health on unwise policies, this article should be
translated into Spanish and Portuguese and given ample diffusion
throughout the Region.
The authors should be commended on their courage and sound public health
principles evidenced in this article.
Competing interests:
None declared
Competing interests: No competing interests
Bonneux and Van Damme point out that the Spanish Flu pandemic in 1918
-19 had a higher mortality amongst younger people than those over 65 years
(1). In the same BMJ issue, Pickles (2) points to the increased world
population and more air travel which may predispose to even more
devastating consequences for a future pandemic. However, what neither
consider are the social circumstances in 1918. The Spanish Flu pandemic
occurred at the end of a devastating four year long world war. Young men
wearied by warfare in the overcrowded and insanitary trenches, prolonged
periods and overcrowding in military ships and trains, young women working
90 hours a week in munitions and other war work, poor nutrition, poverty,
domestic overcrowding, and a medical system largely geared to the needs of
the war may have added to the predisposition and vulnerability of the
population, especially the young, and at least in Europe. One can not
quantify the effects of these socio-economic-military factors on the flu
pandemic, however it would be hard to believe that they had none.
Although there is much to be learned from the past, one must be cautious
in making too direct a comparison between the very different societies and
predisposing vulnerabilities of people in 1918 and today.
Claire Hilton
claire.hilton@nhs.net
(1) Bonneux L, and Van Damme W, An iatrogenic pandemic of flu BMJ
2006; 332: 786-8
(2) Pickles H Using lessons from the past to plan for pandemic flu BMJ
2006;
332: 783-6
Competing interests:
None declared
Competing interests: No competing interests
I have been following the present “flu scare” and feeling outraged by
the money that is being poured in the pockets of the pharmaceutical
industry, instead of using it in urgent and real issues… (almost a million
of children under 5 years of age are dying every year of malaria; BMJ
2006;332:570 ,11 March). Your article, I hope, can help to relieve the
pressure to buy drugs which is presently being exerted on some developing
countries in Latin America, that are these days in the middle of a
necessary and just health care reform. Thank you very much!!!.
Martha Ruben, M.D., Ph.D.
Biomedical Consultant,
Biomedical Writer, Editor,
and Translator (EN<>SP)
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir,
In response to Bonneux and Van Damme and their article “An iatrogenic
pandemic of panic”, some of the statements about neuraminidase inhibitors
are incorrect. Harrison’s textbook of Medicine is quoted as the source of
the statement “the drugs inhibit virus spread within the respiratory
tract, but viral reproduction largely precedes the symptoms.” It is true
that virus is detectable in nasal lavage fluid 24 hours before the onset
of symptoms, but viral load peaks with development of fever, so that at
most, less than a third of infectiousness is thought to be in the
presymptomatic period.1,2 Furthermore, neuraminidase inhibitors are proven
to be efficacious in treating and preventing influenza in clinical trials,
provided they are given early in the course of disease.3 Oseltamivir
nearly halves the duration of viral shedding.3 The major question around
their effectiveness in a pandemic is around development of resistance.4
Vaccine development will be delayed for at least 12 weeks after the onset
of a pandemic, so the crucial role of antivirals is in buying time and
containment before vaccine is available.
Furthermore, it is worth pointing out that the key difference between an
influenza pandemic (or similar emerging infections such as SARS) and other
diseases, is not the cumulative burden of disease, but is that the former
have the capacity to bring the economy to a complete standstill and cause
societal disruption on a massive scale. A few anthrax letter bombs in
2001 brought the entire US postal service to a stop, an event which
illustrates the potential of only a few cases to have a catastrophic
economic impact.5 SARS resulted in severe economic disruption in affected
areas, with near-bankruptcy of some industries such as travel.6,7 This is
why politicians will continue to invest in disaster management planning
around potential pandemics, even if the probability of such a pandemic
occurring is relatively low. And so they should.
Yours sincerely,
C Raina MacIntyre
National Centre for Immunisation Research and Surveillance of Vaccine
Preventable Diseases
And University of Sydney,
Children's Hospital at Westmead
Westmead, NSW, 2145
Australia
1. Al-Nakib W, Higgins PG, Willman J, Tyrrell DA, Swallow DL, Hurst
BC, et al. Prevention and treatment of experimental influenza A virus
infection in volunteers with a new antiviral ICI 130,685. Journal of
Antimicrobial Chemotherapy 1986;18(1):119-29.
2. Hayden FG, Fritz R, Lobo MC, Alvord W, Strober W, Straus SE. Local and
systemic cytokine responses during experimental human influenza A virus
infection. Relation to symptom formation and host defense. Journal of
Clinical Investigation 1998;101(3):643-9.
3. Hayden FG, Treanor JJ, Fritz RS, Lobo M, Betts RF, Miller M, et al. Use
of the oral neuraminidase inhibitor oseltamivir in experimental human
influenza: randomized controlled trials for prevention and treatment. JAMA
1999;282(13):1240-6.
4. de Jong MD, Tran TT, Truong HK, Vo MH, Smith GJ, Nguyen VC, et al.
Oseltamivir resistance during treatment of influenza A (H5N1)
infection.[see comment]. New England Journal of Medicine 2005;353(25):2667
-72.
5. Kaufmann AF, Meltzer MI, Schmid GP. The economic impact of a
bioterrorist attack: are prevention and postattack intervention programs
justifiable? Emerging Infectious Diseases 1997;3(2):83-94.
6. Blendon RJ, Benson JM, DesRoches CM, Raleigh E, Taylor-Clark K. The
public's response to severe acute respiratory syndrome in Toronto and the
United States.[see comment]. Clinical Infectious Diseases 2004;38(7):925-
31.
7. Wilder-Smith A, Paton NI, Goh KT. Experience of severe acute
respiratory syndrome in singapore: importation of cases, and defense
strategies at the airport. Journal of Travel Medicine 2003;10(5):259-62.
Competing interests:
None declared
Competing interests: No competing interests
The impact of media on public behaviour
An iatrogenic pandemic of panic(1) points out the nexus between
experts seeking profile and attendant funding and the media seeking the
next sensational story. The place of government in this process is also
mentioned. A recent incident provides a further illustration of the
response of one government to hypothetical concerns about flu.
On 14 March 2006 the NSW Health Department issued a media release
“NSW Health warns: cover up this winter”(2). The release announced “a
public awareness campaign aimed at reinforcing health messages with the
community to keep people well and avoid seasonal influenza and other
winter illness”. It included advice to the public that “If you have
influenza … wear a face mask when you see your doctor to stop the spread
of disease”. Elsewhere in the release this message was conveyed as
“Individuals with influenza or colds should consider making use of face
masks”. This aspect of the release attracted media attention and was a
feature of television and print media news stories over the following 48
hours.
We describe the impact of the story on patient behaviour observed at
the Inner West General Practice, which has 9 FTE equivalent GPs in the
inner-Western suburbs of Sydney. In the seven days to midnight on Monday
13 March, the practice saw 892 patients, in 8 of whom a diagnosis of upper
respiratory tract infection was recorded on the practice computer system.
In the same period the next week the corresponding figures were 845 and 4.
These figures are likely to under-represent the total number of patients
seen in both periods who would have been eligible to wear a mask on the
NSW Health criteria because cough is said to be a reason for encounter in
5.9% of Australian GP consultations(3). In neither period did any patient
present wearing a mask, although staff did note an increased awareness of
the issue in conversation with patients. Media coverage of advice to wear
a mask has made no impact on their use at this practice.
Data from a wider range of locations is required before these results
can be generalised with confidence. To the extent that the experience at
the Inner West General Practice can be generalised, it may be an example
of government increasing “panic” for limited gain in effective behaviour
change.
1. Bonneux L and Van Damme W. An iatrogenic pandemic of panic. BMJ
2006; 332: 786-788
2. NSW Department of Health. NSW Health warns: cover up this winter,
accessed at http://www.health.nsw.gov.au/# , 21 March, 2006
3. Britt H, Miller GC, Knox S et al. General practice activity in
Australia 2004–05. A joint report by the University of Sydney and the
Australian Institute of Health and Welfare, December 2005, accessed at
http://www.aihw.gov.au/publications/gep/gpaa04-05/gpaa04-05.pdf , 21
March 2006
Competing interests:
Linda Mann is a principal at the Inner West Family Practice.
Patrick Bolton is employed by NSW Health in an unrelated part of the Department
Competing interests: No competing interests