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Remember my piece on the “Swine Flu” hysteria? I wrote it on November 12, that means week 46. The next day, the German Ministry of Health changed the notification rules for suspected and confirmed cases of “Swine Flu” infections

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I typed these terms into Google and picked three links from the first ten results. I found this video, this blog post, and this Daily Express article.
The video purports to be a list of ingredients in the swine flu vaccine and information about these ingredients. It actually contains misinformation (suprise, surprise) and some scaremongering [...]

“Never confuse movement with action.”
- Ernest Hemingway[1]

‘Tis the season of the flu, just like every year. But this year, there’s something different. How different, you ask? Well, let’s take a look at Ukraine:
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“Ukraine is in the midst of what some might call swine-flu hysteria. The country is in virtual lockdown mode, with the government closing schools, universities and movie theaters and banning all public gatherings until the end of November. Pharmacies have run out of protective masks; those who missed the rush are improvising with scarves or homemade facsimiles. And rumors are running rampant, much as they did during Soviet times when the authorities tried to cover up disasters like the Chernobyl nuclear-plant meltdown. “We are worried that the swine flu has mutated and is killing scores of people,” says Nina Sokolovska as she stands in line at a pharmacy.”

A flu that seems as deadly as an out-of-control nuclear reactor? The whole story seems hushed up by the government? Rumours spreading faster than the disease itself? Public gatherings are banned and schools, universities and the likes are closed? Let’s look at this from the beginning.

Influenza and “Swine Flu”

Everyone knows the “usual”, seasonal influenza, but this year there’s also the virus strain of H1N1, popularly called “Swine Flu”. Just like SARS and the “Avian Influenza” (the H5N1 strain, emerging in 2003 and still in the wild), it is a zoonosis, an infectious disease that can be transmitted from animals to humans (or vice versa). And just like the “Avian Flu” in 2005 and 2006 made for sensationalist coverage in the media, precipitous actions by various governments and hysterical discussions in the public debate, so is the “Swine Flu” firing everyone’s imagination.

FARNSWORTH
Dear Lord, they’re back!

AMY
We’re doomed!

HERMES
Dooomed!

[Bender takes a breath.]
BENDER
Doooo…!

Even though the run-of-the-mill variation of the influenza, the yearly seasonal flu “result[s] in about three to five million cases of severe illness, and about 250 000 to 500 000 deaths“ worldwide, whereas the “Swine Flu“ has, to date, taken less than 6300 lives worldwide, less than 700> of those in Europe (this disconnect between victim numbers and media hype is a topic for another day). Funnily enough, very few politicians are recommending to be vaccinated (German former Minister of the Interior, now Finance Minister, Wolfgang Schäuble, has publicly stated that he hasn’t decided yet whether or not to get the vaccine).

Populism and the search for a scapegoat

In the aforementioned case of the Ukraine, the hysteria and fear is coupled with populism: It seems like politicians are adding fuel to the flame in order to score political points ahead of the January elections. Schools and universities are closing, public gatherings have been banned (just days after the big launch of current Prime Minister Yulia Tymoshenko’s election campaign), medication was flown in and the landing plane greeted in a George W. Bush-style photo-op by Tymoshenko – a move so blatantly populist that the local newspapers seem to agree with the political opponent Arseniy Yatsenyuk, who calls this a distraction from the real problems the country is facing. Oh, and on top of all these sweeping measures, Tymoshenko publicly stated that she will not get vaccinated – draw your own conclusions from that.

An even more exaggerated reaction could be witnessed in Egypt, where – prior to any reported (much less confirmed) cases of “Swine Flu” - about 250 000 (!) pigs were needlessly slaughtered. Here, the pigs – and, in a case of guilty-by-association, their Coptic Christian owners - were presented as a scapegoat. This measure sparked not only riots and the (further) impoverishment of the Coptics11, but also a massive garbage-disposal problem: The Pigs, traditionally used to clean the streets of tons of organic waste are now dearly missed, making the authorities’ initial reaction to international criticism during this spring’s mass killings even more ironic:

When health officials worldwide said that the virus was not being passed by pigs, the Egyptian government said that the cull was no longer about the flu, but was about cleaning up the zabaleen’s crowded, filthy, neighborhood.

Historical Parallels

Now, that was a mighty long build-up for a post in the history section of this site, wasn’t it?
But reading about all this reminded me of a certain historical topic. Which one? Society’s reaction to a truly devastating epidemic of a zoonosis. More specifically: Medieval Europe’s reaction to the catastrophe of the Bubonic Plague 1347 – 1351, commonly refered to as the “Black Death”.

The Plague, commonly seen as one of the quintessential events in the history of Europe, comparable in its impact to the Migration Period of the Germanic and Slavic peoples or the First and Second World War, has influenced European society in fields as diverse as politics, economy, arts and – of special importance here – mentality[2]. Some scholars even go so far to call the Plague Years with their estimated 20 - 30 million dead[3] (i.e. about a third (!) of Europe’s inhabitants) the beginning of the end of the Middle Ages[4].

“sterben [...] von eime ende der welte untz an das ander” - “death […] from one end of the world unto the other”[5]

The literal reaction to these few years can still be witnessed, stemming from the originals of Boccaccio (sometimes called the Italian Shakespeare) and Petrarch to more modern writers, like Defoe or Camus. Even in modern times there are plenty of idioms that can be traced back to this deadly disease: The British and Germans alike may try to “avoid something like the plague” (German: “meiden wie die Pest”), the Germans say they “have the choice between plague and cholera” (”die Wahl zwischen Pest und Cholera”) where the English are caught between a rock and a hard place.

So how did the contemporaries react, and where can we draw parallels to our own times?

Patterns of Interpretation

Without going into the details of the medieval concepts of health and disease, let’s take a look at the dominant patterns of interpretation of the Plague:

The people of the 1300’s saw a holistic connection between man and environment, microcosm and macrocosm, everyday life and religion, earthly and spiritual life. Therefore, the main topos found in contemporary literature is the “tribunal”[6] or “God’s righteous wrath”[7]. The inexplicable infection mechanism, the rapid and so often fatal progress of the Plague as well as its more general effect on the society at large brought about a plethora of religious phenomena. First and foremost, the flaggelants spring to mind (even though there are instances of earlier flaggelation-movements), often accompanied by antisemitism (although both were mostly limited to the Holy Roman Empire of the German Nation), the later here functioning as a sort of valve for built-up frustration, as well as serving as a scapegoat (although there were many contributing factors that played out to the Jews’ disadvantage and the social elites that instigated these anti-Jewish riots often stood to gain financially from the Jews’ demise)[8]. Less extreme religious tendencies can be witnessed in the increase in pilgrimages as well as the often held services of intercession.

But there is a paradox here: Even though the Plague was seen both as sent from God and as righteous punishment for society’s sins, the medieval populace still tried to escape the disease by flight, penance and dozens of other actions. Some historians even go so far as to postulate a “scepticism about God’s justness”[9], as is evident in some chronicles:

Oh Genoa, what crime did you commit in these days! Do tell, Sicily, and all you rich islands of the sea, of God’s tribunal! Do explain, Venice, Tuscany, and the whole of Italy, how did you conduct yourselves! We from Genoa and Venice try hard to unravel God’s resolution! Oh pain! When we sent our fleets against [foreign] towns, we turned on our own homes![10]

de Mussis cannot explain what, exactly, brought about the Plague’s torment, God’s tribunal, what is the deed that needs to be paid for. Petrarca even goes so far to ask a question that seemed unthinkable just a few years ago:

Or should it be true, what some great thinkers already suspected, that God does not care for the earthly world [any more]?[11]

Measures taken against the Plague

When talking about the provisions taken against this unprecedented disease, we have to distinguish between the institutions that enacted them: Local authorities, the Catholic Church, and the people themselves. Any ideas that were to be put into practise were not only hampered by the lacking understanding of the Plague itself, but also suffered heavily from the strain the epidemic put on the institutions: Personnel was lacking, civil unrest was spreading and there was little time to react once the first people become infected – and let’s not speak of the unreliability of the rule of law even during the best of times in the middle ages.

The most strain was put on the social networks of the days, the family and the lower clergy. Both were the basic unit of care for the socially weak and ailing, and both suffered horrendously under the Plague: Friends and family did not dare to care for the sick any more, out of fear for their own lives. The lower clergy had even higher casualties than the medical professionals, because they not only supplied basic medical care but also had to administer the last rites[12].

Prophylaxis

While the first organised quarantine likely stems from 1377, even during the Black Death some rudimentary isolation mechanism can be witnessed. On a more basic level, no one wanted to have contact to the fleeing refugees from the already infected neighbouring towns, although the speed of the disease itself makes it seem unlikely that this was a complete or even good isolation: Especially friends and family will likely have breached this informal quarantine.

Some towns instituted a health check at the gates and refused entry for every sick person – sadly, because of the latent period of the Plague is significantly shorter than the incubation period; since another vector was the flea, this measure usually amounted to nothing. Similarly, the idea of improving municipal hygiene was doomed from the start: All efforts to clean up streets that were not paved, consisted mostly of compacted mud and refuse, were swarming with wild dogs and other animals and literally had streams of shit flowing through it were futile[13].

Counteractive Measures

That the bodies of those who had died of the Plague were highly infectious, was apparent to most contemporaries. This was evident in the extremely high death rate of the gravediggers and undertakers[14]. The quick removal of those corpses was often accompanied by an – again, informal – isolation of the deceased’s belongings, as simply no one wanted to come into contact with them.

The burial procedures were shortened and handled less strictly, simply because of the shortage of qualified clergy, but also because fewer people wanted to attend out of fear of infection. Mass graves beyond the city gates were dug, against considerably protest of the local populace who did not approve of the constrains this put on the cult of the death. Sometimes, a maximum number of mourners was set, an obvious but half-hearted parallel to today’s banning of public gatherings.

These measures were usually accompanied by a host of moral laws, banning gambling, Sunday work or swearing in public; increased pilgrimage and mass could be seen, too. And, most interestingly in my mind, is the medieval equivalent to the modern gagging order of the press: The death knell, used to announce a funeral, was often curbed or banned outright, in order to not agitate the populace any further[15].

The Bottom Line

As we have seen, these hysterias are not something that we can point and laugh at in other, supposedly “less educated” or “backwards” countries and times. In Germany, some local school boards have decided to implement a daily head-count of the attending children as a precaution against the “Swine Flu”, some school districts even completely close down whole schools with hundreds of pupils, if just one case of infection is confirmed; some parents refuse to send their kids to schools (German) that aren’t closed if there is a “Swine Flu” case. And the media is to blame, as well: Germany’s biggest tabloid newspaper, “Bild“, had the Swine flu (or the vaccination-controversy) as a lead story 12 times in 27 days (German); let’s just say that serious information probably wasn’t the primary concern here.

As we have seen, the kind of behaviour witnessed today can be traced back to the medieval times and is, apparently, anchored deep in the human psyche. These kinds of fear – when you worry about your own health as well as about your family – are hard to control by education.

Don’t get me wrong: Get vaccinated, if possible against both seasonal as well as “Swine Flu”. Just don’t buy into hype (of any kind) and scrutinise the actions taken and the arguments given for them. Otherwise, imagine what kind of panic the future might bring if this thing actually does get dangerous for the whole of society – for there are historical precedents.

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Footnotes

[1] cf. A.E. Hotchner: Papa Hemmingway, 1966.
[2] cf. Uwe Walter: Der “Schwarze Tod“ und seine Sippe – Versuch einer Bilanz, in: Mischa Meier (ed.): Pest. Die Geschichte eines Menschheitstraumas, 2005, p. 370f. (German).
[3] cf. Karl-Heinz Leven: Art. Pest B., in: LexMA Bd.6, 1993, Cls. 1920f. (German).
[4] cf. František Graus: Pest – Geissler – Judenmorde. Das 14. Jahrhundert als Krisenzeit, 1987, pp. 535 - 550 (German).
[5] Jakob Twinger von Königshofen: Deutsche Chronik, ca. 1400 (Middle High German).
[6] Gabriele de Mussis: Ystoria de morbo sive mortalitate quae fuit anno Domini 1348, in: Bergdolt, Klaus (Hrsg.): Die Pest 1348 in Italien. Fünfzig zeitgenössische Quellen, 1989, p. 22 (German).
[7] Giovanni Boccaccio: Il Decamerone, in: Bergdolt, Klaus (Hrsg.): Die Pest 1348 in Italien. Fünfzig zeitgenössische Quellen, Heidelberg 1989, p. 39 (German).
[8] cf. František Graus: Pest – Geissler – Judenmorde. Das 14. Jahrhundert als Krisenzeit, 1987 (German).
[9] Bergdolt, Klaus: Die Pest. Geschichte des Schwarzen Todes, 2006, p. 10 (German).
[10] Gabriele de Mussis Ystoria de morbo sive mortalitate quae fuit anno Domini 1348, in: Bergdolt, Klaus (Hrsg.): Die Pest 1348 in Italien. Fünfzig zeitgenössische Quellen, 1989, p. 23 (German).
[11] Francesco Petrarco: Brief Francesco Petrarcas an seinen Bruder Gherardo, in: Bergdolt, Klaus (Hrsg.): Die Pest 1348 in Italien. Fünfzig zeitgenössische Quellen, Heidelberg 1989, p. 141f. (German).
[12] cf. Gabriele de Mussis Ystoria de morbo sive mortalitate quae fuit anno Domini 1348, in: Bergdolt, Klaus (Hrsg.): Die Pest 1348 in Italien. Fünfzig zeitgenössische Quellen, 1989, p. 28 (German).
[13] cf. Kay Peter Jankrift: Brände, Stürme, Hungersnöte. Katastrophen in der mittelalterlichen Lebenswelt, 2003, pp. 147 - 180 (German).
[14] cf. Gabriele de Mussis Ystoria de morbo sive mortalitate quae fuit anno Domini 1348, in: Bergdolt, Klaus (Hrsg.): Die Pest 1348 in Italien. Fünfzig zeitgenössische Quellen, 1989, p. 28 (German).
[15] Klaus Bergdolt: Der Schwarze Tod im Mittelalter und in der Frühen Neuzeit, in: Kaldewei, Gerhard (Hrsg.): Pest, Plagen und Polykarpus 1454 / 2004. 550 Jahre St.-Polykarpus-Gilde zu Delmenhorst. Begleitveröffentlichung zur Ausstellung „Pest, Plagen und Polykarpus 1454 / 2004“ vom 13.6. - 5.9.2004 in den Museen der Stadt Delmenhorst auf der Nordwolle, 2004, p.
77 (German).

There has been so much published about H1N1 swine flu in recent months that despite my keen interest in the topic (being an infectious diseases clinician involved with determining policy and strategic pandemic flu planning in my own hospital as well as looking after clinical cases), I can barely keep up with the medical aspects of the disease, never mind the rest of the information. But, as is ever the case, much of the other material that is in the public’s eye seems to be based on uninformed opinion and comment, rather than scientific facts.

One of the more mendacious bits of opinion currently pervading the media is to do with the vaccine and its possible adverse effects. Hardly anyone seems to have a good word for the H1N1 vaccines, and people appear to coming out in droves to say they will not be getting or recommending the vaccine for some tenuous reason or other. Another misleading view is that there has been a huge fuss over nothing because H1N1 swine flu has caused fewer deaths than originally anticipated, and that it may not kill many more people than would ordinarily die from “flu” in any particular season.

So let’s look at the problem from a different viewpoint, because there is a very real risk people may not see the wood for the trees. Forget about all the irrelevant speculation on swine flu and the scaremongering you hear about the vaccine for a moment. They only serve as a distraction from the direct and severe health consequences of this infection. Instead let us concentrate on the simple medical facts:

• There is an illness which is spreading widely across the globe, and it has yet to reach its full extent.
• This illness is usually mild but can be severe, particularly in vulnerable groups of individuals.
• The illness has already directly caused thousands of deaths in Europe and the Americas so far, with most of these deaths occurring within the aforementioned vulnerable groups.
• Because this illness is very widespread, it is causing major disruption to health service provision and will have far-reaching adverse consequences for other people with different health care needs.
• This illness has been identified as being due to a specific virus.
• Scientists have developed a specific vaccine against the virus.
• Vaccines for these types of virus appear to be very effective, as well as very safe, and when the vaccine virus strains match the prevalent circulating virus strains they have been shown to be extremely effective at preventing the illness.

Now if this illness were a disease like leukaemia, or brain cancer, there would be rioting in the streets to demand that the preventative vaccine be made instantly available to everyone. Yet for some reason, many people just don’t seem bothered about H1N1 vaccination, despite the fact that swine flu is predicted to kill more people in a year than would die from leukaemia or brain tumours.

To me this is a no-brainer. There is a specific infection (H1N1) which is making many people ill and is killing a small (but numerically substantial) proportion of them. There is an effective way to stop this happening through vaccination, yet people are reluctant to support this. When one considers the lengths we go to in this country to avert deaths from other diseases, the indifference that many display about H1N1 swine flu beggars belief.

Climate chief, Lord Stern of Brentford, has said that we should give up meat to save the planet from global warming.

While it’s undeniable that rearing herds of animals for meat is bad for the environment, is vegetarianism the answer - or even an answer? This is not an entirely scientific response to Lord Stern but there are a few points more serious responses have missed that have occurred to my flu-addled brain.

In order to provide vegetarians with dairy products, cattle must be bred. But only females are needed for milk. The males will not be sent off to live out their lives happily in green pastures; apart from a few kept for breeding, they will be slaughtered. The same goes for male chicks in egg production. The bodies will have to be disposed of, either as landfill or by burning, both of which have health and ecology implications.

Apart from environmental issues, this also removes any moral high ground from vegetarians. What’s more, in Veggie World, anyone who eats meat but not dairy would be forced into veganism. That’s not just lactose intolerant Westerners but a large proportion of the population of Asia.

Veganism may be the only true moral position regarding the exploitation of animals. But it has its problems as vegans don’t eat honey. The bees that produce honey also pollinate crops as well as wild flowers and other flora essential to a healthy eco-system. Wild bees are not enough. So if we all became vegan, the planet would be headed for disaster unless we all kept bees as pets (not such a bad idea).

What would Veggie World be like?

Pigs would disappear. Children would grow up learning about them as semi-mythical beasts from the past, along with dodos. Or possibly they could see them in zoos. People who overeat could no longer be meaningfully compared with pigs. The film Babe might be mistaken for a historically accurate tale of pig farming. Sheep and goats would go too, apart from a few breeds used for cheese. Breeding sheep for wool would probably end as wool is a non-essential fabric. All the religious iconography and symbolism about lambs would become obscure. The Lamb of God and the Good Shepherd would become empty images. None of this is necessarily a bad thing.

Humans aren’t the only ones who eat meat. What would cats and dogs eat? If humans have to stop eating meat, feeding it to pets could hardly be justified. Apart from guide dogs and police dogs, man’s best carnivore friend would become a thing of the past. Farmers wouldn’t need dogs any more as there would be no sheep to herd. One Man and His Dog would never be seen on TV again. Nor would Crufts. Again, not necessarily a bad thing if it meant that Ben Fogle was on TV less. There would be no dog poo in the world either. The Andrex puppy would be no more. The Internet would no longer be flooded with pets in cute poses or dressed up in clothes. A whole section of the greetings card industry would be threatened; no more pictures of fluffy puppies and kittens.

Macdonalds would either go out of business or switch to making meat-flavoured veggie burgers. We’d all be eating a lot more beans to get our protein. Methane produced by farm animals farting is one of the contributors to global warming but six billion people farting constantly is not going to do the ozone layer any favours. Incidentally, rice paddies also give off methane.

We do eat more meat than is good for the planet and many of us eat more than is healthy for us but as far as vegetarianism being the solution - Stern really hasn’t thought this through.

ETA: I now appear to have swine flu. The irony is not lost on me.

Yesterday, I went to a talk given by Edzard Ernst at Bradford University. The talk was based on the book he co-wrote with Simon Singh: Trick or Treatment. This is my (unsystematic) review.
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Professer Ernst began by telling us that the book has received much criticism from advocates of alternative medicine - and was met with bewilderment from some, who seemed surprised that a professor of complementary medicine would criticise CAM. To that, Ernst said that:

An uncritical scientist is a contradiction in terms.

His introductory slide included statements to the effect that:

• A large proportion of the general population uses CAM
• Patient population figures for use of CAM are much higher
• In the UK, we spend £1.6 billion on CAM each year
• Even the most fundamental questions remain unanswered

Slide number two highlighted four ways of attempting to find out if something works: plausibility; the test of time; ask the patient; do the research.

Bloodletting was used as an example for each of the first two options. Plausibility: Ernst pointed out that (at the time) bloodletting was seen as a plausible treatment because of the belief that health was affected by the status of the four humours. He then went on to point out that acupuncture (based on the principles of “yin and yang”), chiropractic (based on the idea of “subluxations”), homeopathy (based on the principle that “like cures like”), and reflexology (based on the idea that points on the foot correspond to the internal organs of the body) are utterly implausible. Although he then pointed out that implausibility doesn’t necessarily rule out a treatment being effective.

As for the test of time, Ernst noted that bloodletting was used for hundreds, if not thousands of years despite being ineffective. He then quoted Oscar Wilde: “experience is the name we give to our mistakes”, which I thought was a rather neat way to illustrate the problem with assuming that the longevity of a treatment was a reliable measure of its effectiveness.

In tackling the option ask the patient, Ernst showed a slide from Marja Verhoef that showed a hierarchy of the factors important to patients. “Gut feelings” were at the top of the pyramid, “trial-and-error” and media articles were also listed but I was unable to note all the factors or the order of importance of the factors. There is an abstract of a qualitative study conducted by Verhoef and others which lists types of evidence relied upon by cancer patients searching for information on complementary therapies.

Scientific evidence ranked very low for most patients. Anecdotal evidence was among the top types of evidence patients relied on.

Then we came to research. Ernst related the proposal made by Jan Baptist van Helmont in 1662. Thanks to the James Lind Library, I am able to reproduce the quote:

‘Let us take out of the hospitals…200 or 500 poor people, that have fevers, pleurisies. Let us divide them into halves, let us cast lots, that one halfe of them may fall to my share, and the other to yours; I will cure them without bloodletting and sensible evacuation; but you do, as ye know…We shall see how many funerals both of us shall have.’

This was perhaps the first time that an RCT had been proposed. Unfortunately, it wasn’t until 1809 and Hamilton that a trial of bloodletting is believed to have taken place. Ernst then moved on to James Lind himself and the famous trial of treatments for scurvy. The James Lind Library has a commentary of the trial here: link. Ernst informed us that one of the treatments tried was “hard labour” and explained that as one of the symptoms of scurvy was lethargy, confusion over cause and effect had led to the belief that this may be a useful treatment. His comment that hard work was believed to be a treatment for “lazy bastards” brought laughter from the audience. I had expected the talk to be rather dry, but was pleased to note several moments where humour was employed by the professor.

Acupuncture

Ernst referred to a positive trial by Berman et al that studied the use of acupuncture for osteoarthritis, then pointed out that we must beware the cherry-pickers. A single trial cannot be expected to prove the efficacy of a treatment, but systematic reviews are more reliable. While acupuncture has been touted as a panacea (cure-all), Ernst noted that it has only been shown to be effective for pain and nausea.

Chiropractic

This section of the talk began with discussion of the origins of chiropractic, which some may have been surprised to find was not invented as a treatment for back problems. A slide was shown that listed systematic reviews of chiropractic spinal manipulation for various conditions alongside percentages of chiropractors who (wrongly in most cases) believed that chiropractic was an effective treatment.

Ernst then moved on to the risks of chiropractic, noting that mild to moderate adverse effects of the treatment were not disputed - in comparison to severe adverse effects which were hotly disputed. Discussion of chiropractic ended with a slide showing a pair of scales labelled “harm” and “benefit”, with the harms being shown as heavier than the benefits.

Homeopathy

Beginning with a slide showing a homeopathic pamphlet featuring Queen Elizabeth II, we were told that the royal family were “staunch supporters” of alternative treatments such as homeopathy. Ernst went on to say that the treatment was based on the principles that “like-cures-like” and “less-is-more” - principles that are totally implausible. Ernst told us of a study he had conducted into homeopathic arnica which made him “very unpopular with British homeopaths” (who were “quite outraged” - but which was later confirmed by two independent systematic reviews.

Noting that some homeopaths complained that trials of homeopathy that did not study individualised treatment of patients, Ernst referred to a trial of individualised homeopathy for childhood asthma which provided no evidence that individualised homeopathy was superior to placebo as an adjunctive treatment. Cautioning us once more against the reliance upon single trials, Ernst then told the audience of a systematic review of systematic reviews. I believe this is the paper in question: abstract on Pubmed. Ending the section on homeopathy with reference to harm and benefit, Ernst discussed the possibility that, while an inert treatment such as homeopathy may not cause harm, homeopaths themselves might - for example by offering homeopathy as an alternative treatment for swine flu. Again, the slide showing a pair of scales with the balance tipped towards “harm” was shown.

Ernst digressed from discussion of the four complementary / alternative therapies at this point to point out that he doesn’t see himself as a “Quackbuster” - but as having to choose whether or not to tell the truth about his investigation of complementary and alternative therapies. Telling the truth seems to lead to him being labelled as a Quackbuster. Ernst then pointed to studies into St John’s Wort for depression as an example of investigation into CAM that found an effective therapy, before pointing out the risks (particularly that St John’s Wort can interact with prescription medication). Leading on from this discussion of an effective CAM treatment, Ernst moved to the last of the four therapies that were the focus of his talk.

Reflexology

Ernst points out that reflexology may be relaxing and thus beneficial for patients. While the theory behind reflexology is implausible, massage therapy can be beneficial. I have struggled to find the systematic review of massage therapy Ernst referred to, but believe that this may be it: abstract on Pubmed. On the whole, the evidence was positive (albeit there were concerns over methodology). From the abstract:

[the trials] suggest that massage can alleviate a wide range of symptoms: pain, nausea, anxiety, depression, anger, stress and fatigue.

Summing-up

We were told that CAM is popular, used by patients, and in fact is driven by patients. Because of this, Ernst believes it is important to address the general public. He pointed out that of the research into CAM:

…you find some gems in this mess but you find a lot of disappointing results.

He then reaffirmed his stance that he is not a Quackbuster, but is a scientific investigator.

Questions

Having invited questions from the audience and promised a copy of his book for the three best efforts, the first questioner was a gentleman who had got his copy of Trick or Treatment signed by Ernst before the lecture and hence did not need a copy as a prize. He asked about the gold-standard of trials, the RCT, and whether there were problems with this approach to discovering the truth about medical therapies. Ernst stated that while there were problems with RCTs, they were the best option we had for investigating treatments. Referring to the issue that trials of this nature tell us about the group rather than individuals, Ernst reminded us that in medical science we must deal in probabilities.

A question about placebo brought a response to the effect that the placebo response can be powerful. The professor then pointed out that a genuine treatment given by a practitioner who was able to empathise with the patient would have both specific and placebo effects. CAM treatments that are no better than placebo cheat us of the specific effects that genuine treatments can offer.

A lady sitting to my left then asked about clinicians’ views (with reference to the hierarchy of patients’ views Ernst had shown us earlier). Ernst replied that clinicians often rely on experience rather than the best available evidence - and that “that is wrong” (I paraphrase here, as I cannot remember the verbatim quote).

There was also a question about the regulation of CAM (with regard to the Prince of Wales’s FIH and the CNHC, better known as OfQuack). Ernst pointed out that regulated nonsense remains nonsense and complained that CAM practitioners have no requirement to use the evidence-based medicine.

More

Unfortunately, there were many elements of the talk (and questions & answers following the talk) that I failed to note down. I hope that my scrawled notes and imperfect memory have conveyed an accurate impression of the views of Professor Ernst but I would not be surprised to find that my notes and memory of the event are both far from perfect. I have also failed to recall or to make note of the humourous moments of the talk which brought laughter from the audience.

My overall impression was that Ernst is keen to engage with the general public and to inform them about evidence-based medicine and also the pitfalls that they should avoid. For example, being misled by cherry-pickers giving single studies as proof of a treatment’s efficacy, or reliance upon inadequate evidence of other kinds - such as anecdotal evidence.

Tonight I’ll be speaking at Conway Hall (tickets still available), but in the meantime I have a problem - I’ve contracted some sort of cold flu swine flu Ebola, and I need to get rid soon. I was contemplating heading to Boots and buying an armful of lovely drugs and pharmaceuticals, but the helpful advisors of @ofquack showed me a better way.

Yes, it’s a homeopathic cure for Ebola:

Dr. Gail Derin studied the symptoms of Ebola Zaire, the most deadly of the three that can infect human beings. Dr. Vickie Menear, M.D. and homeopath, found that the remedy that most closely fit the symptoms of the 1914 “flu” virus, Crolatus horridus, also fits the Ebola virus nearly 95% symptom-wise! Thanks go to these doctors for coming up with the following remedies:

1. Crolatus horridus (rattlesnake venom) 2. Bothrops (yellow viper) 3. Lachesis (bushmaster snake) 4. Phosphorus 5. Merc. cor.

If you are not in the U.S., you must locate your closest homeopathic practitioner and ask him or her to order these remedies for you from Hahnemann Pharmacy, (510) 327-3003 (Albany, California, a suburb of Oakland). If your country’s laws allow you to call a homeopathic pharmacy directly, do so. In any case be sure to find a homeopathic practitioner you can work with. Do not try to take care of yourself without the further education and experience that a homeopath can give you.

If you’re not sure where to find your closest homeopath, call the National Center of Homeopathy, (703) 548-7790, Take this article with you and let a homeopath read it and instruct you on how to use the remedies.

Now, there’s a lot of stuff contained in the above nugget of stupidity that I could pick up on, so let me just pick up on two points.

Firstly, Ebola can cause death (from systemic multi-organ failure) in as little as two days. That gives me enough time to attend the TAM fringe tonight, but finding my nearest homeopath, getting them to place an order for the remedy with a clinic in San Francisco, having the remedy shipped here and then getting treated in two days is a feat beyond the capabilities of even Jack Bauer.

I will be dead by the time it arrives, and they can bury me, clutching the vial, as mourners mutter “if only DHL got their act together.”

The second point that amused me was the assertion that: “the remedy that most closely fit the symptoms of the 1914 “flu” virus, Crolatus horridus, also fits the Ebola virus nearly 95% symptom-wise!” So in other words, this quack believes that Spanish Flu and Ebola are 95% the same symptom wise. Let’s just check this:

Flu Symptoms: Fever, nausea, aches, diarrhea, pneumonia, dark spots on cheeks, bleeding in lungs.

And now Ebola:

Ebola Symptoms: Fever, nausea, aches, diarrhea, severe headache, abdominal pain, severe weakness, exhaustion, sore throat, dizziness, internal and external bleeding, joint pain, dark or bloody faeces, vomiting blood, bleeding eyes, petechia (broken capillaries), maculopapular rash, purple discolorations of skin, low blood presure, tachycardia, hypovolemia (low blood volume), disruption of clotting, altered white blood cell count, bleeding from incompletely-healed injuries, external haemorrhae from orifices including nose and mouth.

So, yes, remarkably similar symptoms really, apart from the heart problems, massive internal bleeding, haemorrhages from every orifice and wotnot. Oh, and the fact that the two diseases are caused by completely different viruses.

I have no idea where Dr. Vickie Menear got her doctorate from, but the above article is probably the stupidest thing I’ve read on the internet today. And that’s an achievement. Anyway, I’m off to the pharmacy for some proper drugs. See you tonight.

I’ve broadly agreed with most of the articles I’ve read by Dr Crippen, but I was less than impressed with one on swine flu and vaccination published this week by the Guardian.

The Daily Mail were involved in scaremongering about the MMR vaccine, but later characterised parents who failed to vaccinate their children as morons and blamed Andrew Wakefield for starting the scare. At one point, the paper was publishing articles in England bashing the HPV vaccine while at the same time running a campaign in Ireland [...]

Potions & Possibilities, makers of high-end toiletries and aromatherapy products, are claiming their products to be effective in the control of deadly swine flu.

A document circulated on the internet lists “Top 10 tips for natural infection control”. Originally circulated in May, it was reissued again in July. The document contains elements of sensible advice scalped from the the Department of Health (”Catch it, Bin it, Kill it“) blended with outrageous nonsense of a more profitable kind. For instance, here is founder Julie Foster’s recipe for a “sanitiser room spray”:

…as above but add 5 ml of Geranium to the vodka and top up the mix with 100ml of water. Use in a spray or tie pre-soaked ribbons to the bars of a domestic fan to diffuse into the room.

“What is Geranium?”, I hear you ask. Well, according to the Potions & Possibilities website, it’s a fragrant oil that “has a close affinity with the female system” and is “emotionally soothing”. If that doesn’t get rid of airborne flu virus, I don’t know what will!

Tea tree oil features heavily in Foster’s advice, undoubtedly because it has known anti-microbial properties. Foster seems to believe that it is “the most powerful antiseptic known to man” which explains why the Army used it to eradicate anthrax spores from Gruinard Island. Oh no, wait, that was formaldehyde, wasn’t it? My bad. Still, if you’re infected with the early stages of swine flu, Foster believes that the smell alone of tea tree oil will protect you:

Apply a few drops of premium, therapeutic Tea Tree Oil onto the fabric between bra cups or on outer clothing at the neck where it won’t show. Your body’s heat causes the Tea Tree to rise so that you are constantly breathing in this amazing oil with its antiviral and antibacterial powers.

Potions & Possibilities also produce a range of herbal soaps in conjunction with that cathedral to alternative nonsense, the Royal Palaces. Herbs are harvested from the royal gardens and processed in Suffolk for sale in palace shops. In a perfect world, someone with the power and education that comes with such a fortuitous accident of birth would be living up to his title as Protector and saving us from charlatans like Foster. As it is, the Prince is a dogmatic defender of indulgent make-believe, and it’s up to broke state school guttersnipes like me to point out the fantasies touted by herb sellers.

Julie Foster says she is available for additional comment and expert aromatherapy and natural health advice. Perhaps you could ask her for evidence to support her claims for aromatherapy as an effective prophylactic against swine flu. You can contact Foster through Sharon Lovett on 07971096725 or 01394 386161 or email: sharon@potions.co.uk.

Thanks to Brendon for the original source.

Read the comments on this post…

[BPSDB]It would appear that there is more to Natural News than Louise Mclean’s homeopathy factoids. There’s this where the American anti-government paranoia combines with the antivaxxer mind set to produce ravings whose last tenuous connection with reality has been broken.
CNN apparantly reported that “the U.S military is gearing up to get involved in the H1N1 [...]

Guest post by British doctor DeeTee. See more by DeeTee here.

As the swine flu pandemic tightens its global grip, antivaccinationists far and wide are gearing up for their propaganda war against the H1N1 vaccine. Their objections, predictably enough, conform to the usual diet of antivaccine canards that they always employ to frighten people about vaccines, but the novelty of the current pandemic offers them unlimited scope for scaremongering among the millions of worried potential vaccine recipients.

Are there any valid reasons to have concerns over this flu vaccine? Well, possibly, but not to the extent the antivaccination lobby would have us believe. There are still issues that need to be resolved, some of which are strategic rather than scientific in nature such as whether the vaccine should be mandatory or not. Regarding the science it is as yet unclear exactly how protective the vaccine will be, and studies are under way to determine the correct balance between HA antigen dose and immunogenicity, which will influence both the incidence rate of reactions and also determine how effective it will be in the groups most in need of it. It may be that two doses are required for optimum protectiveness, and studies to look at this are under way. The technology used to produce vaccine is not new; essentially all that is being done is to tweak the antigenic components of the seasonal vaccine, which has a very good safety track record.

But the antivaccine lobby are indicating that they are deeply concerned, and they wish all of us to share their concern to the point of refusing vaccination. Now any rational person with the slightest modicum of common sense will be able to dismiss as irrelevant their usual froth about “toxic” ingredients in the vaccines, but there are some reading their diatribes against flu vaccine who might be worried, particularly when “real science” is disingenuously quoted by the antivaccine crew to support their case. One such “valid” concern is the link between influenza vaccination and an uncommon neurological disorder, Guillain-Barré Syndrome (GBS).

Of all the side effects reported after flu vaccine, GBS holds sway as the most prominent in the minds (and mouths) of the antivaccinationists. A direct causal relationship has never been clearly established between flu vaccines and GBS, but the link is biologically plausible and the available epidemiological evidence points to an association. The concerns about swine flu vaccine in particular first came to light when GBS affected over 500 people following a mass influenza vaccination programme that took place in the USA in 1976.

So what are the true facts about GBS? Firstly, it must be made clear that the most common causes of the syndrome are naturally acquired infections (although other triggers are reported). Now all infections can trigger a host immunological response, but rarely in certain individuals this host response is misdirected to cause damage to the myelin coating of nerve cells, causing GBS. This process of demyelination results in weakness and paralysis, which can take months to resolve, and it can rarely be fatal (although much less so nowadays with the advent of treatments such as plasmapharesis and immunoglobulin infusions). There are a number of infections known to trigger GBS, Campylobacter jejuni gastroenteritis being the best-known example.

Vaccines, containing as they do microbiologically active agents, might reasonably be assumed to pose some risk since their action mimics that of the natural infections, hence the concerns about vaccine-induced GBS. This immune-mediated process might operate either through molecular mimicry, or through “bystander activation”, but clear evidence that these actually occur with flu vaccines is weak and inconsistent.

In 1976 there was an outbreak of influenza among US servicemen stationed at Fort Dix in New Jersey that resulted in several hundred clinical cases and one death. The strain identified was a novel Hsw1N1 “swine flu” virus, similar to the 1918 pandemic Spanish flu strain which killed half a million people. Fear that another 1918-type pandemic was about to occur prompted the authorities to begin mass vaccination and a total of 45 million Americans were vaccinated against swine flu. In fact there never was a significant outbreak, not because the population was protected by vaccine, but because transmission of the virus remained confined to Fort Dix by the infection control measures implemented at the time.

Following the vaccination campaign, there was a rise in the numbers of GBS recorded that year, with 581 cases being reported by the CDC in Atlanta. This led to speculation that the vaccinations were responsible, but the number of reported cases was disputed since there was felt to be some bias in the collation of data and the criteria for diagnosing GBS. Subsequent reanalysis conducted by the CDC’s Immunisation Safety Branch rejected 29% of the reported cases of GBS. One of the possible theories as to why the vaccine might have caused GBS was that the vaccine had been contaminated with Campylobacter jejuni, since at that time this infection was common in poultry and the vaccine was produced in chick embryos.

Ever since, there has been concern that influenza vaccines given for seasonal flu might cause the same problem, particularly when in the USA in 1994 when the numbers of cases of GBS rose to 74, having been only 37 the year before. These reports prompted The Institute of Medicine to set up a Safety Review Committee to study the links between influenza vaccines and neurological syndromes. The IOM reviewed all available evidence regarding GBS post vaccination, for which there were many detailed analyses available. In 2003 they reported “the evidence favored acceptance of a causal relationship between the 1976 Swine Influenza vaccine and GBS in adults.” However, the evidence for other years was “inadequate to accept or reject a causal relationship”. The estimated risk of GBS after flu vaccine is currently thought to be around 1 to 2 cases per million vaccinated persons per year.

An association between influenza season and a rise in the incidence of GBS has been noted before, with the suggestion that influenza infection itself might be a cause. However, it is often difficult to dissociate what might be due to influenza infection from what might be due to influenza vaccination – obviously both are common during flu season. As the authors of the study commented: “Whether the associations [of GBS] with influenza are real or whether they reflect seasonal patterns in influenza vaccination is unclear.”

The role of influenza was clarified in a recent French study published as a major article in the in-house journal of the Infectious Diseases Society of America. This not only looked at epidemiological data on GBS but also tested all the cases microbiologically to establish the causative agent. In 18% of GBS cases they investigated, influenza infection was shown to be the cause. They also estimated that the incidence of influenza-related GBS to be 4-7 cases for every 100,000 cases of influenza.

So where does this evidence leave the antivaccine lobby’s claims about GBS and swine flu vaccine? Essentially nowhere. That GBS might be triggered by flu vaccine is possible; it certainly seems as though 33 years ago it may have done so with the vaccine produced at that time. Whether the current swine flu vaccine will do anything similar is questionable; flu vaccines produced since 1976 do not appear to have significantly raised the risks of GBS above the background noise level, and any epidemiological rise in GBS cases during the flu season may not be due to the vaccine but actually caused by influenza. In fact the most powerful argument in favour of continuing to have flu vaccine (thereby running a tiny, one or two in a million risk of GBS) is that flu itself is a relatively common cause of GBS, and would appear to cause it once in every 14,000 to 25,000 episodes of flu. Running the risks of a rare vaccine side effect is perfectly acceptable when the risks from not having the vaccine are much worse.

I predict that the supposed risk of GBS will be one of the more specious reasons bandied about by the antivaccine lobby in the coming months as a reason why we should avoid the flu vaccine. And it’s not just the rabid antivaccine websites promoting this view, there have already been articles in the “quality” UK papers questioning the value of vaccination, as exemplified by this one in the Times by Dr Halvorsen, a prominent antivaccine proponent with his own new antivaccine book to promote (and profit from). He claims: “The case for vaccinating millions of healthy adults against a disease that is no more unpleasant than a bad cold is questionable”. This completely ignores the evidence that for certain susceptible groups, influenza infection may be extremely serious. Now I have looked after many patients who have died from influenza, but never anyone who died of “a bad cold”.

Halvorsen goes on to say this about widespread vaccination: “We could expect hundreds of people to get GBS, some of whom will suffer permanent paralysis or die.” If as many as 30% of the UK population receive the vaccine, and if the rates of GBS compare with those experienced after the USA 1976 flu vaccine programme (which is unlikely as there is no reason to anticipate the same rate of reactions now as there were in 1976), there might be between 166 and 200 cases attributable to vaccine (based upon the described risk of one case in 100,000-120,000 vaccinated persons). But if the rate of vaccine-associated GBS conforms to that thought to occur with more current flu vaccines (1-2 per million), we could expect only between 20 and 40 cases.

However, any estimates of vaccine-associated GBS cases must be set against the risks of flu-associated GBS. If as many as 30% of the UK population get swine flu this autumn (as is widely predicted), we might anticipate around 800 cases of flu-induced GBS. One might reasonably conclude that, given all the available scientific evidence, having flu vaccine is actually a very logical and effective way to prevent GBS in a pandemic flu scenario. But I don’t expect antivaccine proponents like Halvorsen to appreciate this fact, since they only ever look at risks from the vaccine and never the risks from the disease.

The reasoning behind this antivaccine propaganda is entirely spurious, and like all of the other risks we are so solicitously warned about, the fears are manifestly unjustified. Of course vaccines can and will cause reactions; after all they are biologically active products. But the potential benefits of the influenza vaccine, particularly for those in higher risk groups, far outweigh the potential harm from reactions. The risks of problems such as vaccine-associated GBS are significantly less than the risk of influenza-induced GBS, and are miniscule compared to the serious risks that can arise from influenza and its other complications.

Come the autumn, when are flu vaccine is offered to health care workers, I hope to be at the front of the queue. I just hope that in the interim I can avoid catching swine flu from one of my patients, since I cannot predict whether I will be one of the 800 or so in whom the infection might trigger GBS, and I cannot predict if I will be one of the many thousands who will die from complications of influenza. Or perhaps for Halvorsen’s benefit I should rephrase that to read: “I cannot predict if I will be one of the many thousands who will die of a bad cold.”

The Times have published an article by Richard Halvorsen on vaccines (apparently, he has a book on vaccines coming out next month). Background: Halvorsen runs a clinic that offers single vaccines for measles and rubella (at a cost of £95 each) and he has written and commented on vaccines and autism.

Simon Jenkins, having already established his ignorance of the science of swine flu, is now offering dangerous medical advice.  In an article in today’s Guardian, largely composed of conspiracy theorising over big pharma, anecdotes instead of evidence and bluster replacing intellect, Jenkins offers up the following:
I do not want to dent the soaring profits of [...]

Guest post by British doctor DeeTee. See more by DeeTee here.

As the H1N1 swine flu pandemic gathers pace, with 29 deaths to date, the attitude of the public seems to vary from rank indifference to blind panic. This view is reflected within my own hospital, where news of a possible flu admission is greeted by some staff saying “so what?” while others demand the equivalent of a biological “hazmat” suit before they get within a mile of a case.

One of the intriguing aspects has been the poor grasp people have on how quickly epidemics can evolve and what factors can influence this. Having spent some time recently reminding myself about the mathematics behind the spread of epidemics, I thought it would be a good idea to highlight some of the underlying principles.

Reproductive Numbers.

The extent of spread of any infection such as flu depends on how “contagious” the virus is. For an infection to spread within a population, an infected person has to pass it on to at least one other person. Depending on its degree of infectiousness, each infection may be allocated a number indicating its likelihood of spreading rapidly, representing the number of people on average who will be infected by one other case. This is known as the Reproductive Number, signified mathematically as R0. If an infection has an R0 of greater than 1, it will spread exponentially and become an outbreak or epidemic, but if it is less than 1, it will soon die out (hence the old adage that 1 is the most important number in epidemiology). But Reproductive Numbers can be variable, and are also situation specific (e.g. it will be higher in a children’s playgroup in Birmingham than in a rural Scottish village). The R0 for influenza is estimated to be between 1.5 and 3, and around 2 on average (by comparison the R0 for measles is around 15, and polio around 12, indicating their higher potential for spread).

But don’t think flu having an R0 of 2 is good news. A useful analogy for the transmission of an infection like flu through a population is the spread of gossip. Let’s imagine you have a unique bit of gossip; perhaps you know that a well-known local celebrity has got secretly engaged and you just cannot resist telling a couple of acquaintances. If they each tell 2 other people, you can see the starting of an epidemic of gossip (with R0 = 2). If the gossip is passed on every hour (although with texting and twitter, it would probably travel further and faster), how many people might have heard the gossip within a day? This question formed the basis of a scenario I ran by some non-clinical colleagues at work recently. Their answers ranged from a paltry “150″ to an impressive-sounding “Ten thousand”.

Or what if your gossip was not quite as juicy, and it only infects only one other person on average (R0 = 1)? Perhaps to get your news onto the grapevine you wish to give it a boost, by emailing it to 200 people in the company. After 24 hours, which method/infection type will have resulted in the most infections?

Most of those I asked indicated that this second situation would result in the most infections. In fact the gossip with R0 of 1, despite getting a big kick-start, can only infect a possible maximum of 4800 people. (200+200+200 and so on for 24 generations). However, the gossip with an R0 of 2 will have infected a gob-smacking 33,554,430 people, or over half the population of Britain (2+4+8+16+32+64 and so on for 24 generations). Any potential bioterrorists reading this please take note: You can efficiently generate a globally-devastating epidemic by infecting just a couple of people with a pathogen with a high R0. There is no need to contrive a massive release of biological agents by detonating germ-filled explosives in the skies over New York or in the Paris Metro. (Movie producers, feel free to ignore this tip and continue doing what you always do).

In practice however, epidemics of infection often quickly run out of steam, even if they have a high R0. Clearly you are unlikely to infect over 33 million people with your tittle-tattle of celebrity gossip. The obvious flaw lies in the fact that after a few generations it will be hard to find someone in the localised population who has not already heard the gossip, so they cannot be “infected” anew, and the further spread of gossip will cease, and the epidemic collapses. (Some of you will also realise this is the reason why moneymaking scams like pyramid selling and ponzi schemes will all fail within a short time of being created). The gossip’s R0 starts out as 2, but then drops as there are fewer and fewer people to potentially infect anew, and once the R0 drops below one, the epidemic burns itself out unless new vulnerable populations continue to be infected.

In 1927 a mathematical model of epidemics was devised by Kermack and McKendrick. This supposes there are 3 classes of individuals, namely those who are susceptible (S), those who are infected (I), and those who are recovered (i.e immune)(R). This is the SIR “compartment” model (and unfortunately further exploration of it requires differential equations beyond my understanding, so my foray into it must come to a grinding halt). It is sometimes adapted to SEIR, for Susceptible, Exposed, Infectious, and Recovered, for infections where there is a significant latent period between infection taking place and the ability to infect. For those of you interested in the background to compartmental modelling, there is a good overview on wikipedia.

As unfeasible as the gossip scenario for flu might seem in practice, it does illustrate the potential infections have to spread explosively. Various estimates are that half the UK population could still get swine flu, so is the gossip analogy valid and what does it tell us about real infections? Could they eventually infect millions of people in the same way? The answer is yes, but there are many other factors at work.

Let’s use the analogy to look at some of these. You tell two work colleagues your celebrity gossip. One of your friends tells her manager, and later on the other friend tells some of the staff in accounts. The epidemic is under way. However, within a day or two, you find that most of the staff in your company have heard the news. They are no longer susceptible, having become “immune” through already having been exposed to the gossip previously. These individuals are like the real-world examples of those who have recovered from an infection. According to the SEIR model, they are “recovered” and are now immune to catching it again, and will not pass it on even if re-exposed, and the pool of “susceptibles” has declined rapidly. Some of the people hearing the gossip could also be regarded to be “immune” because although exposed to your gossip, they couldn’t care less about it, don’t give it a second thought and wouldn’t dream of telling someone else. These are the equivalent of people who have been immunised by vaccination. An important point to remember is that not everyone in the company will hear your news. Perhaps the cleaners who only come in at night or the staff who work in the post room remain blissfully unaware of it because they fortuitously avoided coming into contact with anyone who was infectious.

Herd Immunity.

The gossip analogy is useful to explain the dynamics of other aspects of an outbreak, like the protection afforded by herd immunity. Let’s say someone visits your company from head office a few days later. A bit behind the times, he mentions the celebrity engagement by way of conversation. But by now this is old news in your workplace, the 3 people he tells it to are already immune, having already heard the gossip the previous week and they don’t bother mentioning it to anyone else. This is herd immunity at work. A sufficiently large proportion of the people in your company have been immunised to such a degree that new infections will not be able to spread easily. They make up a protective “herd”, and the still susceptible cleaners (even now they have switched to the day shift) will never get to hear the gossip.

Generation Time.

Another crucial factor that determines the rapidity of spread of an infection is the “Generation Time” (Tg), or the interval it takes between one individual becoming infected and passing it on to the next. Some infections will spread more rapidly than others, even though they have a similar R0, just because they have a shorter generation time. For example, the 1918 pandemic influenza strain had an R0 of around 2, which is about the same as does HIV. The difference is that the generation time for flu is only about 2-3 days, whereas for HIV it is many months, and often several years. This explains why flu pandemics seem to zip around the globe, while the HIV pandemic has chugged along at a relatively sedate snail pace. (Bioterrorists take note once more: Choose an agent with a short generation time as well as a high R0).

Calculation of susceptibles versus protected/immunes

There is a simple and useful formula for calculating the number of people in a population who need to be “susceptible” before an outbreak or epidemic is likely. This is most often used to estimate the proportion of the susceptible population that needs to be immunised in order to avert outbreaks. If the proportion of susceptibles in the population drops below 1-1/ R0, then outbreaks are likely.

For measles, 1-1/ R0 is 1-1/15 (or 93.3%), hence the advice that we need measles vaccination rates of 90%-95% to avoid outbreaks. For influenza, 1-1/R0 is 1-1/2, or 50%. So if half the population is immune from having had the swine flu before or because they are vaccinated, a major epidemic is unlikely. Obviously with the current swine flu epidemic, there are very few who are immune to H1N1 (which last touched our shores in 1957) and as yet there is no vaccine, so the epidemic would appear to be unstoppable.

Strategies for Management.

The dynamics of epidemics tells us something about how they are best managed. Initially in the UK, the plan was one of containment, where any suspected cases who had travelled to the UK from Mexico or the USA would be isolated, treated and all close contacts given antivirals to prevent them being infected. This it was hoped would contain the epidemic by rendering the R0 <1 and reducing spread. Unfortunately, once widespread onward transmission took place in the general population, this ring-fencing became impracticable, and the shift is now towards treatment and isolation of cases only as they occur. Some estimates indicate that if the R0 for influenza were less than 1.6, then a system of isolation and targeted antivirals would be successful. The fact that this has not succeeded with swine flu indicates its R0 is greater than this, and more likely to be around 2, as for the 1918 H1N1 epidemic.

The mathematics here involves not just R0, which is the most relevant factor, but also latent periods, infectious periods and generation times, which are again is too complex to delve into here. A good overview of the influence of these can be found here.

Infections are fascinating. One of their most intriguing and unique qualities is their ability to spread, often explosively, causing major epidemics of disease or pandemics. Infections have helped shape evolution, history and civilisation, and have ranged from the biblical plagues of antiquity to the more modern global devastations wrought by malaria and AIDS. People usually don’t give more than a passing thought to the historical relevance or consequenses of infection, but occasionally this apathy is punctured by episodes of sheer panic, as is currently happening with swine flu. If nothing else, I hope this blogpost has given food for thought, and hopefully not resulted in even greater concern about the consequenses of swine flu, which fortunately does not seem to be any more lethal than the usual outbreaks of seasonal influenza.

Due to Sods’ Law, just after I posted my last Swine Flu piece I came across a 15 year old girl named Ella. Ella is quoted in the Independent (something I somehow missed last time I looked at it) as having attended a swine flu party, so is this the first evidence that these parties have actually taken place? (HT: “sTeamTraen”)

Here’s the piece:

I have been to a swine flu party – but it didn’t start out like that. It was a regular teenager’s party until the conversation turned to swine flu and it turned out that my friend’s boyfriend has it so it’s likely that my friend, who is also 15, does as well. Everyone started laughing because the idea of a friend having swine flu was quite funny. It was one of those things that you hear about on the news and think will never affect you.

Then, the “swine flu party” started: a coughing fit from my friend all over everyone else.

Yes, lovely. So to begin with, this wasn’t actually a swine flu party, just a bunch of teenage girls - none of whom apparently have the flu - spontaneously coughing over each other.

But Ella isn’t just some average kid they found; she has apparently been writing for the Independent since 2008, covering everything from reviews of the latest Harry Potter to articles about the teenage view of sex . Prior to that she appeared in The Telegraph aged just thirteen. It’s a bit cynical to present her as an average kid who happens to have been involved in swine flu parties when neither part of that is really true.

Now, it’s not fair to criticise Ella for this. The girl has talent, and anyone with the skill, talent and maturity to be writing for the national press in their early teens should be encouraged - she is undoubtedly a great kid. However, one has to question the ethics of the editor in using this sort of story. It’s all too reminiscent of, well, this guy:

I want to start with a graph, or rather a pair of graphs, taken from Google Trends. These aren’t particularly accurate and should be taken with a pinch of salt, and the same pattern is not reflected in the United States, but they illustrate a worrying point. The graph at the bottom shows media mentions of swine flu parties in the United Kingdom over time, while the top graph shows search volume from British users.

<!–break–>
Broadly speaking then, it appears that much of the public’s interest in swine flu parties, as crudely measured by Google search results, was prompted by coverage of the phenomenon in the media. This begs the question, to what extent did these parties exist prior to the media coverage of them? Did newspapers report the story, or create it?

The reason why these parties are such a bad idea should be pretty obvious - they involve deliberately making children ill, the majority of whom would never have been ill in the first place; and if enough people take part they cause the illness to spread much more rapidly through the population than it would otherwise. With vaccines not yet widely available and health workers racing to prepare ahead of the expected winter outbreak it’s a particularly short-sighted approach to take, and of course there’s no guarantee that little Tarquin will be immune anyway.

The response of the British government and media to swine flu has been generally poor and dithering. Swine flu is a very genuine threat, but it’s the sort of threat that’s hard to convey to the public - possibly very dangerous but unpredictable, and likely to be slow moving for many months. Media coverage inevitably veered wildly between predicting “Parmageddon” and mocking the “scare-mongering”. In the meantime, swine flu has spread, affecting several thousand people and killing a handful so far - children have been particularly vulnerable. The failure to contain the pandemic in the UK led to the government abandoning their containment strategy last week and adopting an aggressive treatment policy.

Against this background, the first mentions of swine flu parties appeared on Mumsnet.com, an internet forum frequented by middle class mothers. As the website’s founder, Justine Roberts, explained to The Independent, there was no evidence that any parties had been arranged, merely a discussion of “the principle of whether it might be a good idea.” Roberts gave an odd defense of this thinking in The Independent:

“Ms Roberts said she believed parents had become confused by the Government’s policy of keeping schools open while at the same time telling them to take all precautions against their children contracting the virus.

‘No one wants to cause hysteria, she said. ‘The Government has an agenda, I assume, about having to control the infection, but the truth of the matter is either you should get it now or try to avoid getting it – you can’t have it both ways. It’s so easy to give a glib representation of ignorant parents who are acting hysterically.’“

The government, I imagine, took the view that mass closures of schools that would be breaking up for the summer soon anyway, during exam periods, would be going to far, but what I don’t understand is how the suggestion that people should continue to go about their ordinary lives, while remaining vigilant, is somehow morphed into “you should get it now.”

At any rate, at the time of writing I’ve seen no evidence whatsoever that any such parties have actually taken place. The entire story seems to be based on claims from a person promoting a parenting website that the idea has been discussed on an internet forum. In short, it was a non-story.

And yet on the basis of this non-story, Roberts was interviewed by national newspapers, mentioned in Time and appeared on radio shows to ‘debate’ public health policy with health professionals. In the Independent article I cited earlier, a website owner is given 4 paragraphs in which to state their views, while the Government’s chief medical officer Sir Liam Donaldson, representing the views of basically the entire British medical profession, gets just two and a bit!

Of course there is a case for reporting and addressing the concerns of parents. Doubtless government advice can be confusing (and at times confused), and so responsible coverage of the issues involved is a Good Thing. The problem is that, as far as I and others who have researched this can make out, swine flu parties don’t exist. Far from addressing the issue, Roberts is being given a vast platform on which to promote it (and of course her website). In all probability the vast majority of parents had never even heard of or considered the idea before it burst into the newspapers.

So the story of the swine flu parties was never real, but there’s a certain relentlessness about the largely unconscious creation of the media myth. There’s no reason to believe that at any stage people made things up - rather a grain of truth was shaped and polished and embellished in a machine that seems to run on autopilot. The result is a fusion of fact and myth that exists in its own reality, and yet - if the rough results from Google Trends are anything to go by - is beginning to distort our own. By the end of the summer, the story could well be real, and if it is then it will have been created by the media.

This is a long rambling post dissecting the arguments of one Tom Vizzini with regards to swine flu. It may or may not be of interest to you, but I had to get this out of my head so that I can sleep, and to that end I’ve put it here. Read it if you [...]

Thanks to Ian for this classic advert, seemingly dating to around the flu pandemic 1918. Just like the classic “Guinness is good for you” ads, Bovril tried to get in on the action by claiming their beef stock drink has prophylactic powers:

It seems to be a whole campaign, appearing everywhere, from pubs to plates, to magazines.

Thanks to the Advertising Standards Authority, private companies can no longer make unfounded medical claims for their products. It’s not like anyone is profiteering from the current swine flu panic is it?

Oh wait, except chiropractors. And homeopaths. And herb sellers. The spamdemic is the best thing to happen to quacks since the last major global health scare.

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Bored of swine flu? Why not evolve your own killer virus, bacteria or parasite and unleash it on the world…

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The author of Bad Science, Ben Goldacre, commented yesterday that his article on Swine Flu was “possibly the most boring thing I’ve ever written for the Guardian,” and indeed there’s a certain yawn-inducing tedium that I can already feel infecting me as I write this. It’s not so much the virus that’s boring - flu is a fascinating subject, honestly - but the farcical, playground level of the public debate.

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Patrick Holford has broken his (unaccountable) silence about pandemic fears around Mexico City flu (aka, swine flu). Take vitamin C. Jab more vitamin C into your veins. Black elderberry makes it harder for viruses to enter your cells. Roll up.

Courtesy of the brilliant XKCD

Thanks to Sandy for letting me know about the Center for Disease Control’s Twitter Feed, which will keep you up to date with the current swine flu outbreak. Latest news is 20 confirmed cases in the US, with one hospitalisation, and clear human-to-human spread. Over at Effect Measure, Paul Revere has a well-informed running commentary of the emerging virus.

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[bpsdb] It’s close to becoming a truism now that every unusual event is immediately greeted with a chorus of conspiracy theories, and Swine Flu is no exception. If you want to see some extremely impressive analysis of the situation, then you should head on over to the guys at Effect Measure, who are putting the mainstream media to shame. But the people I’m about to present to you have a rather different take.

As an example of just how different this take is, the title of the piece I’m about to quote is “It is Time to Shoot Back.”

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