H1N1 pandemic or panic?

Dr. Tom Jefferson’s research is a powerful antidote to rampant bio-evangelism

The amount of death and disease would be less if all disease were left to itself. – (1835) Dr. Jacob Bigelow, prominent US physician and botanist

He should be one of the most famous people on the planet right now, lauded for his research and a consultant for the most powerful health policy makers and planners in the world. The immense clarity he has brought to what we know about vaccines and influenza could even launch him as a candidate for the Nobel Prize in Medicine. Yet Dr. Tom Jefferson, a British physician who works out of an office in Rome, lives largely in anonymity and despite the resonance his name might have in relation to the famous American who authored the Declaration of Independence, this Tom Jefferson is hardly a household name.

 

This is odd, given that, as we close a year which will be remembered as ‘The Year of the Damn Panic’ – I mean pandemic – his research would have helped stifle the fear mongers and wind back the influenza panic currently holding the world hostage. Dr. Jefferson is a member of the Cochrane Collaboration’s Acute Respiratory Infections Group, a group of researchers, epidemiologists and clinical experts who pour through the world’s evidence around influenza and respiratory infections. His group has published dozens of meta-analyses, essentially critical summaries of studies based on the world’s body of scientific evidence around the treatment of flu and flu-like illnesses, synthesizing it, and telling us what we can and cannot say with certainty about the effectiveness and safety of flu vaccines. (Check out the online resources at www.cochrane.org/influenza/)

Dr. Jefferson’s research brings some clear-headedness to the flaming bio-evangelism that has been swirling the planet since June when the World Health Organization declared the world was in the midst of an influenza pandemic. This WHO declaration, who some claim to be fraudulent as it was largely derived from a redefinition of the word ‘pandemic,’ sent national governments around the world scrambling in a frenzy of vaccine and antiviral drug stockpiling, creating pandemic preparedness plans and stoking the world’s media to print headlines announcing SOMETHING BIG was afoot.

Preparing the public to face a virus of unknown, but potentially huge, lethality evoked the spectre of the 1919 Spanish flu and heightened anxiety among public health officials who carried out a lot of hand wringing (and hand washing) about what to do.

With such high stakes, did the world’s national governments seek out the best evidence surrounding flu treatments and consult with the world’s best and most knowledgeable assessors of that evidence? After all, given our deep belief that clinical medicine (and health policy) is based on a foundation of scientific research, you might have assumed, as I did, that poring through the evidence around influenza preventative interventions would have been the highest priority in this year of the pandemic. Wouldn’t you?

Yet you’d be wrong.

In their scurrying to rush vaccines to market and otherwise construct a large-scale, multibillion dollar public health exercise, there was only one thing the public health experts forgot to do: to look at the evidence around the flu vaccines and the antiviral drugs they were so keen to promote. If they’d taken the time to understand the work of Dr. Tom Jefferson and his colleagues at Cochrane, they would have understood the evidence was on Mars and the prevailing recommendations around mass vaccinations for the flu were on Venus.

When I called him at his office in Rome, Tom Jefferson was just finishing off a review on the evidence around hand washing, which was commissioned by several national governments. He’s a busy man lately, revising and updating reviews and trying to avoid some of the weirdness that might come with being a researcher in an area of such global importance. He tells me about recently turning down an offer to appear on a talk show on US television, saying “I do reviews; I’m not exactly a ballerina.”

The current pandemic craziness that has much of the globe in its embrace clearly mystifies and engages him. He framed our discussion by referring me to a recent review he’d written for the British Medical Journal of Philip Alcabes’ book, Dread: How Fear and Fantasy Have Fueled Epidemics From the Black Death to the Avian Flu. In his review, he poses a particularly pertinent question: “Why and how had a relatively benign disease such as influenza been turned into a fund-raising, raging monster at our door? Why had poorly performing vaccines and flopped antiflu drugs been turned into money spinners and career builders by governments?”

It’s what I was about to ask him.

Dr. Jefferson points to a central, simplistic equation that is used to fuel pandemics, drive research agendas and suck public health agencies into action: “One germ equals one disease equals one solution (pill or vaccine).” In his opinion, things aren’t that simple and from our wide-ranging discussion, I have tried to synthesize some of the key soundbites and conclusions I was left with:

If you get flu symptoms, you don’t necessarily have ‘THE’ flu.

He tells me it’s necessary to distinguish between those viruses that we can immunize against – influenza A and B) – from perhaps up to 200 other known viruses and many unknowns that circulate. All these viruses can cause similar symptoms, what the researchers call “Influenza-Like Illness” (ILI.) and the vast majority have no vaccines or proven preventative treatments. Dr. Jefferson reminds me that, through systematic reviews, his group has found that influenza is actually a relatively rare disease. Of 100 people in the population in the wintertime, approximately between seven and 10 will experience flu symptoms yet only one will actually have one of the influenza viruses A or B. So what we’re talking about here is vaccinating for a ‘disease’ that may afflict one percent of the population over the two to three months of its maximum circulation.

For whom is the flu vaccine effective?

Generally, looking at the published research, flu vaccines aren’t that effective. There is no evidence they’re effective for children under two, yet they can help prevent symptoms in older children and healthy adults; they hasten return to work by half a day, on average. There is poor evidence that the vaccines work in people with chronic conditions or that they prevent death in the elderly. There is no credible evidence that they prevent complications from bronchitis and pneumonia in all age groups and there is little evidence that they are safe to take in pregnancy. That, of course, is different from saying they cause harms as there is little hard evidence of that either. The fact that the vaccines appear to prevent what is called “all-cause mortality” may be an artifact of how they are studied and reflect research that is based on comparing the health of people who get vaccinated versus the health of those who don’t, which we call the healthy user effect. Basically, flu vaccines are shown to be more effective in people who already appear to be quite healthy.

What about antivirals like amantadine, rimantadine or oseltamivir (Tamiflu)?

The first two are relatively bad drugs; they won’t interrupt transmission and don’t prevent infection. Newer drugs like Tamiflu have fewer harms and are more effective in alleviating symptoms and reducing the length of symptoms even as there is increasing evidence that they may be linked to harms, especially psychiatric harms.

What about non-drug or non-vaccine approaches?

Some non virus-specific interventions work best and the bonus is that they can work for all viruses, not just the ones for which you can vaccinate. These include good personal hygiene, distancing, hand washing or wearing gloves and gowns, which is probably impractical for the average person. The highest quality evidence suggests that the spread of respiratory viruses can be prevented by hygienic measures around younger children – more hand washing.

What about flu vaccine safety?

As Dr. Jefferson has said, “New vaccines never behave in the way you expect them to.” It may be that there is a link to GBS (Guillain-Barré syndrome), a nervous system disorder that can cause paralysis, but it could end up being anything because some of the new additives have not been studied sufficiently or the data are inaccessible.

 

At the end of the day, Dr. Jefferson agrees that the story is fascinating and very complex. I told him I was surprised about the poor quality of the evidence given the billions being spent on vaccines alone for this pandemic and he reminded me that the quality of policymaking seemed even worse. He pointed to a piece he published in the Journal of Clinical Epidemiology, which clearly lays out how poorly government influenza recommendations seem to adhere to the available evidence.

Having seen the poor quality of the evidence, Dr. Jefferson argues that flu shots need to be subjected to more rigorous testing so we can ensure that vaccine programs are successful at lowering rates of flu cases and deaths. There seems to be a Grand Canyon-sized gap between what we know and what has been recommended during this ‘Year of the Pandemic’ and this does nothing to instil public confidence in those who have been charged with keeping the public safe.

Alan Cassels is a drug policy researcher at the University of Victoria. He has maintained that on the day his local health authority announces it will vaccinate the public as part of a randomized controlled trial, he will roll up his sleeve: As he claims, “If they randomize, I’ll immunize.”

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