Suzi Wizowaty

Fear is a powerful tool. It regularly motivates us to do all kinds of things we might not do otherwise, from obsessively brushing our teeth (which I do) to invading other countries.

But it's not a tool I choose to use, nor do I admire its use by others. Where I am afraid, I try to apply reason. I depend on cautious skepticism and curiosity to counter my own fears. ("Be more curious than afraid," Ishi's father said to him, for anyone who remembers that fine eponymous book.)

Based on what I've read of the flu, I have to admit that I am as concerned about the erosion of the public trust by hype as I am about this particular flu season. Whom do we believe? How virulent will this particular strain turn out to be? What precautions are sensible to take? If this flu turns out to be relatively benign, what then? Remember the story of The Boy Who Cried Wolf? When the wolf finally did come, no one believed him. I grew up in Houston, where we regularly heard about old-timers in Galveston who tired of hurricane warnings and decided to sit out the one storm that wound up washing away half the town. These are the dangers of hype.

Caution isn't always wise, but fearful overreaction is never wise. In order to be capable of swift, effective action, a government must have a history of thoughtful deliberation.

So below are some excerpts from (and links to) interviews with Dr. Tom Jefferson of the Cochrane Collaboration. The CC is an independent group of scientists "that produces what are widely believed to be the most respected and objective reviews in medicine." (David H. Newman, M.D., Hippocrates' Shadow, p. 37)

But first, a note of explanation. I do not oppose the H1N1 vaccine or any other vaccine; I don't know enough to do so. So what's the big deal? What am I so worried about? It seems to me that mass inoculation as a public health policy deserves a more thoughtful conversation. The public--every patient, always--has the right to know about all the risks and benefits of any treatment. If it's true that a significant percentage of parents (30-60%, depending on what you read) plan to decline the H1N1 vaccine for their kids, then we haven't addressed the issues adequately.

In the meantime, those of us fortunate enough to have doctors can talk to them about what's right for us. And all of us can sneeze into our elbows and wash our hands as often as possible--and avoid taking health care advice from anybody (like me) who's not otherwise qualified!

Dr. Jefferson's interview with Der Spiegel:
http://www.spiegel.de/international/world/0,1518,637119,00.html [Sorry, you have to cut and paste these into your browser; this blog function doesn't allow live links in this column.]

TJ: [Y]ou have to distinguish between an influenza-like illness and a genuine flu, the real influenza. Both of them have the same symptoms: a sudden high fever, a sore throat, coughing, rheumatic pain in the back and legs, possible bronchitis and pneumonia. But real flues, real influenzas are only caused by influenza viruses, while there are more than 200 different viruses that cause influenza-like illness … Approximately 7 percent of influenza-like illness cases are caused by influenza viruses. It's a very small percentage. What I know is that real influenza is systematically overestimated.
[...]
SPIEGEL: For a number of years, as part of the Cochrane Collaboration, you have been systematically evaluating all the studies on immunization against seasonal influenza. How good does it work?

TJ: Not particularly good. An influenza vaccine is not working for the majority of influenza-like illnesses because it is only designed to combat influenza viruses. For that reason, the vaccine changes nothing when it comes to the heightened mortality rate during the winter months. And, even in the best of cases, the vaccine only works against influenza viruses to a limited degree. Among other things, there is always the danger that the flu virus in circulation will have changed by the time that the vaccine product is finished with the result that, in the worst case, the vaccine will be totally ineffectual. In the best of cases, the few decent studies that exist show that the vaccine mainly works with healthy young adults. With children and the elderly, it only helps a little, if at all.

SPIEGEL: But aren't those the exact groups that influenza immunization is recommended for?

TJ: Indeed. That's one of the contradictions between scientific findings and practice, between evidence and policy.

For a study on the effectiveness and safety of flu vaccines on children, see http://www.cochrane.org/reviews/en/ab004879.html
Abstract: "The review authors found that in children aged from two years, nasal spray vaccines made from weakened influenza viruses were better at preventing illness caused by the influenza virus (82% of illnesses were prevented) than injected vaccines made from the killed virus (59%). Neither type was particularly good at preventing 'flu-like illness' caused by other types of viruses (33% and 36% respectively). In children under the age of two, the efficacy of inactivated vaccine was similar to placebo. It was not possible to analyse the safety of vaccines from the studies due to the lack of standardisation in the information given but very little information was found on the safety of inactivated vaccines, the most commonly used vaccine, in young children."

For an interview between Tom Jefferson and Margaret McCartney of (London’s) Financial Times on line:

http://blogs.ft.com/healthblog/2009/09/11/interview-dr-tom-jefferson-and-pandemic-flu-vaccines/

MM: So what kind of testing should there be on new H1N1 influenza vaccines before they are used widely?

TJ: Do we know they are safe, or what the side effect profile is? No, we don’t. We rely on forecasting with seasonal influenza vaccine - and some safety things - like injection site marks - and on past performance. The best evidence we have is for use in healthy adults - where there’s limited benefit - and there is none for use in pregnancy, yet. Do we have a mechanism for dealing with vaccines which perform poorly or not at all? Not evidently. Do we know if these pandemic flu vaccines will do better? We don’t.

Finally, a brief commentary and clarification from The New Yorker:
http://www.newyorker.com/talk/comment/2009/10/12/091012taco_talk_specter