New evidence suggests that widespread underreporting of the incidence of the disease may have skewed the figures showing a 15 fold decrease in the disease after the introduction of routine vaccinations in 1992.

Before the introduction of the vaccine, the disease was already known to be underreported. However, researchers at the University of Warwick say that, with the advent of routine vaccination of children under five, the effectiveness of routine surveillance declined by 23 per cent. This has resulted in an overestimation of the effectiveness of the immunisation programme.

Poor surveillance may also be a factor in the overestimation of the effectiveness of other vaccines, such as the meningitis C, say the authors (BMJ, 2000; 321: 731-2).

* In a recent study, one third of 773 individuals involved in a road accident as a driver, bicycle rider or pedestrian experienced some level of anxiety, depression, fear of travel or post traumatic stress disorder (PTSD) 3 to 12 months later and, in most cases, persisted. After one year, about half the group had phobic travel anxiety, nearly 60 per cent had general anxiety, and half were diagnosed with PTSD (Am J Psychiatry, 2001; 158: 1231-8).

* New research in nearly 1300 men suggests that, during a severe asthma attack, men are less likely than women to notice the symptoms of the attack. The reason for this is unclear, but it may be that men perceive less discomfort because of greater lung size and muscle strength, or because they generally develop asthma at an earlier age than women. Men also tend to only seek medical attention when symptoms are too severe to ignore, the researchers noted (Ann Emerg Med, 2001; 38: 123-8).

* What’s lurking in that paddling pool? Physicians in Canada have found the first outbreak of a new type of Pseudomonas infection called ‘hot foot syndrome’. This discovery was made when 40 children, aged 2 to 15, developed intense pain in the soles of their feet within 40 hours of using the same wading pool. A hot, red swelling began after a few hours, along with pain so severe that the children were unable to stand up. Three children were given oral cephalexin (an antibiotic) while the others were treated with cold compresses, analgesics and foot elevation. In all cases, the condition resolved within 14 days, although it recurred in three children after they revisited the same pool (N Engl J Med, 2001; 345: 335-8).

It is hoped that, at best, Tamiflu may help avian flu victims in the first few days after catching the virus. It is specifically designed to treat symptoms of influenza A and B viruses. Nevertheless, while avian flu is an influenza A virus, each type has numerous subgroups that are determined by HA (haemagglutinin) and NA (neuraminidase) proteins. Altogether, there are 16 HA subtypes and nine NA subtypes, so an influenza A virus can have a unique chemical profile that makes it difficult to counteract with drugs.

More worrying is the safety profile of Tamiflu. The Japanese health authorities have reported that, so far, eight people have died after being given Tamiflu. Dr Rokuro Hama, head of the Japan Institute of Pharmaco-Vigilance, says that all of the victims have been children and adolescents between two and 17 years of age.

Two of the victims were teenage boys who behaved abnormally after being given the drug, said Chugai Pharmaceuticals, Tamiflu’s distributor in Japan, according to an online website (SABCNews.com). Earlier this year, a 14-year-old boy, after taking one Tamiflu capsule, jumped or fell from the ninth floor of an apartment building. In another case from last year, a 17-year-old boy left his home during a snowstorm, and jumped in front of a truck and died after taking the drug. Doctors say that, in both these cases, the boys had not exhibited any abnormal behaviour before taking the drug.

In addition, Japan’s health ministry has received reports of 64 cases of psychological disorders associated with the vaccine over the past four years.

This is not the first health alert for this drug. In 2003, the Food and Drug Administration (FDA), America’s drugs regulator, issued an alert that Tamiflu might be dangerous if taken by children younger than one year old. Following this warning, Roche issued a letter that instructed doctors not to prescribe the drug to very young children as animal studies had suggested that it could be fatal.

Both these reports are worrying developments for a drug that Roche had consistently maintained is ‘well tolerated’. Side-effects were thought to be relatively benign and transitory, and include nausea and vomiting. Other effects that have been regularly reported include diarrhoea, bronchitis, stomach pain, dizziness and headache.

Tamiflu shouldn’t be taken by anyone with kidney or liver disease, or any chronic condition. Pregnant women and breastfeeding mothers are also not advised to take the drug as there are insufficient data from human studies to determine its safety.

Furthermore, although it is regularly given to children and adolescents, its safety has never been established in children younger than 18 years of age as a flu treatment, or among 13-year-olds as a preventative.

It’s been documented that American scientists have genetically reconstructed the deadly Spanish flu virus, which was so virulent that it killed even fit young adults rather than the usual elderly and infirm. Work on resurrecting the virus began as far back as the 1950s, when scientists tried unsuccessfully to retrieve it from victims buried in the Alaskan permafrost. In the mid-1990s, Dr Jeffrey Taubenberger, from the US Armed Forces Institute of Pathology, screened tissue samples from the victims of the 1918 outbreak. He worked on lung tissue from a 21-year-old soldier who died at Fort Jackson, and discovered intact pieces of viral RNA for analysis (Science, 1997; 275: 1793-6).

Other scientists continued what Taubenberger had begun and, by 2002, four of the eight viral RNA segments he had recovered had been sequenced in their entirety, including the two that are thought to be the most important for the virulence of the virus: the genes for haemagglutinin (HA) and neuraminidase (NA) (J Virol, 2002; 76: 10717-23).

The tests were carried out under the strictest security by the US Department of Agriculture in Athens, Georgia, and vials of the virus have since been moved to an undisclosed location, the Centers for Disease Control (CDC) has announced.

But a watchdog group, the Sunshine Project, claims that this is simply not true. It says that vials of the deadly virus have been sent to five laboratories, including one in Canada. The Sunshine Project claims that none of the laboratories, other than the one in Winnipeg, is completely secure, and fail to meet the rigid requirements set out in the biological safety level-4 (BSL-4) code for biological containment.

The biodefence programme has already witnessed several laboratory accidents, including the mishandling of anthrax and plague, and there is one instance of laboratory-acquired infection from tularaemia (caused by the bacterium Francisella tularensis), a zoonosis that can be caught by humans from animals. A researcher in Russia contracted the fear-inspiring Ebola virus while working on it in 2004, and later died.

Researchers know that it wouldn’t take much to spark a pandemic. Influenza viruses can be transmitted via a standard aerosol can, and just a few samples of a virulent virus would be enough to trigger a pandemic (J R Soc Med, 2003; 96: 345-6).

W e are all in the grip of avian-flu hysteria. The World Health Organization (WHO) estimates that the virus could claim up to 7.4 million lives around the world if it successfully mutates and becomes transmissible among humans, while the UK’s chief medical officer Sir Liam Donaldson says it’s a matter of when and not if.

When it happens, it could claim the lives of up to 750,000 Britons, he estimates while, in America, it may kill up to two million people, warns President Bush.

While there are many types of avian, or bird, flu, the disease strain that is worrying health officials is the influenza A (H5N1) virus, first discovered in a flock of terns in South Africa in 1961.

While H5N1 is usually strictly for the birds, a case of infection among humans was first reported in 1997, during an outbreak in poultry in Hong Kong. It caused a severe respiratory illness in 18 people, killing six. Since then, human infections have been reported in Thailand, Vietnam and Cambodia during major H5N1 outbreaks in poultry. Around half the infected humans have died.

Outbreaks among poultry have become common, especially in Southeast Asia and, this year, cases have been reported in poultry farms in Europe. Domesticated poultry catch H5N1 from wild birds, which carry the viruses in their intestines.

As far as researchers have been able to establish, virtually all of the human cases have occurred among poultry workers who had direct contact with the birds or with infected areas. Poultry workers who work among domesticated chickens, ducks and turkeys are at risk because the virus can be passed to humans via the birds’ faeces.

Several cases have been reported where a sufferer has been able to infect another person but, so far, there is no evidence that it has been passed on beyond a limited contact group. Officials at the Ministry of Public Health in Thailand reported a typical example in 2004. It involved a poultry worker who had become infected, and who then transmitted it on to her mother and aunt who came to care for her at her hospital bedside. The mother died of pneumonia after being at her daughter’s side for 18 hours; the aunt also developed pneumonia, but survived. Both were found to have the H5N1 virus (N Engl J Med, 2005; 352: 333-40).

In both these cases, the viral infection was transmitted only after extended exposure.

Another study, carried out at the National Pediatric Hospital in Hanoi, Vietnam, showed that it is not highly infectious. Researchers at the hospital questioned 83 staff members, all of whom had been exposed to four confirmed cases of H5N1 infection; of the staff, just two, or 2.4 per cent, were possibly infected with the avian flu virus (Emerg Infect Dis, 2005; 11: 210-5).

So far, it’s been reckoned that the H5N1 virus has killed around 65 people over eight years. To put this in perspective, around half a million people die of seasonal flu every year, including 40,000 Americans and 12,000 Britons (Drugs, 2004; 64: 2031-46).

Why is an epidemic predicted?
Why should scientists suddenly fear that the H5N1 virus is likely to mutate soon, and become transmissible among humans, when it has been around for at least 50 years?

There appears to be no scientific basis for the dramatic public warnings that are being issued. One reason given is the rising number of outbreaks in poultry farms around the world, and the increased exposure to humans.

But scientists also point to the cyclical nature of viruses. The world seems to be hit by a major flu pandemic three or four times a century. The major epidemic of the last century was the Spanish flu outbreak that occurred in the United States during 1918-19, killing 40 million people. There were also flu pandemics in 1957 and in 1968 – and the WHO has pencilled in 2005-06 as the date for the next outbreak.

However, 40 years elapsed between the first flu pandemic of the 20th century and the second, followed by 10 years between the second and third – which can hardly be viewed as a predictive pattern.

Scientists made similar warnings over the SARS (severe acute respiratory syndrome) virus in 2003, which was also expected to become a major pandemic. Like H5N1, it started in Asia before spreading to the West, where it seemed set to reach Canada. The Canadian health authorities – so concerned by the threat – allowed the United Nations and the WHO to take over the day-to-day responsibility for controlling any outbreak.

In the event, SARS proved to be a damp squib, killing fewer than a thousand people worldwide.

Why flu drugs don’t work
All flu viruses change antigenically to evade recognition by the host’s immune system. These modifications take place rapidly and often – a flu virus can mutate up to a million times more often than a DNA virus (Vaccine, 2002; 20: 3068-87). Vaccine designers at the WHO Global Influenza Program have to prepare new antigen formulations every year, often nine months ahead of the next major flu outbreak. Their role is therefore mainly predictive as they try to second-guess what the new flu virus strain will be to achieve a perfect antigenic match. Only the vaccine that is a perfect match to the virus can combat it, and achieving this is almost impossible, given the infinite permutations that the virus can undergo (Lancet, 2005; 366: 1139-40).

Ironically, and not surprisingly, the perfect flu vaccine is always a year too late.

Over the past 40 years, the drug industry has produced four major antiviral drugs to combat flu – amantadine in 1966, rimantadine in 1993, zanamivir in 1999, and oseltamivir, marketed as Tamiflu, also in 1999 – and resistance to all four is regularly reported (Lancet, 2000; 355: 827-35; J Infect Chemother, 2003; 9: 195-200).

The hope, therefore, that any one of these can combat a virus that has not even crossed over into humans is futile. And yet, Tamiflu is consistently promoted as the main weapon against the H5N1 virus. The US government has placed an order for 20 million doses at a cost of $2 billion (USA Today, October 8, 2005), while the UK government is ordering 14.6 million doses, even though America’s advisors at the Centers for Disease Control and Prevention (CDC) in Atlanta, GA, have gone on record as stating that there is no vaccine to protect people against the H5N1 virus (www.cdc.gov/flu/avian/gen-info/facts.htm).

Protecting against avian flu
At its worst, the avian flu has killed fewer than half the number of poultry workers who have been infected, according to WHO statistics. However, if it truly is as lethal as we have been warned, it surely should have eventually killed everyone it infects. This suggests that a healthy body, and a properly functioning immune system, can withstand any viral attack.

* Supplements

– Vitamin A is one of the most important nutrients for establishing a healthy immune system. It helps maintain the surface tissues that line the eyes as well as the respiratory, urinary and intestinal tracts which, in turn, act as physical barriers against bacteria and viruses (Clin Infect Dis, 1994; 19: 489-99; J Nutr, 1995; 125: 1211-21).

It also helps to regulate the immune system by enabling lymphocytes – the white blood cells that fight infection and disease – to do their job more effectively.

Vitamin A is found in cod liver oil, which is also rich in vitamin D, and meat, oily fish, cheese, and whole milk and eggs, which are also rich sources of retinol, the active form of vitamin A.

Taken as a supplement, an effective dose is between 8000-12,0000 IU/day.

– Vitamins C and E, which are antioxidants like vitamin A, are also well established as immune-system enhancers. Vitamin E is especially effective for reducing susceptibility to infections (Arch Immunol Ther Exp, 1987; 35: 207-10).

A dose of around 200-400 IU/ day of vitamin E, and 1000 mg/day of vitamin C, is recommended to boost the immune system.

– Zinc is another potent antiviral. In one study, a zinc nasal gel significantly reduced the duration of a cold (Ear Nose Throat J, 2000; 79: 778- 80). The more popular zinc lozenges appear to be less effective (J Am Med Assoc, 1998; 279: 1962-7).

– Echinacea is supposed to be one of the most effective immune boosters among the herbal remedies, although the hard science to back the claims of its advocates is inconclusive (Arch Farm Med, 1998; 7: 541-5). Like zinc, Echinacea seems to be at its most effective if taken during the first hours of infection (J Fam Pract, 1999; 48: 628-35).

– Hydrastis canadensis, or goldenseal, is another herbal standby but, again, the science behind it does not support its high reputation.

– Andrographis paniculata, or Kalmegh, an Ayurvedic remedy, is a more effective herbal that has been successfully tested against placebo in two studies (Phytomedicine, 2000; 7: 341-50).

– Elderberry is an effective antidote to the flu. In one study, 60 flu victims took either 15 mL of elderberry extract or a placebo, four times a day for five days. The elderberry relieved symptoms four days earlier than did the placebo (J Int Med Res, 2004; 32: 132-40).

– Phytolacca americana, or pokeweed, is another herb that is known to stimulate the immune system – and it’s especially effective against flu viruses (Antimicrob Agents Chemother, 1980; 17: 1032-3), although it can be toxic if taken over the long term.

* Exercise

– Regular, moderate exercise is good for improving immune function (Exerc Immunol Rev, 1997; 3: 32-52). But bursts of heavy exercise may have the opposite effect, and can suppress the immune system for several hours, thereby increasing the chances of an upper respiratory tract infection (Int J Sports Med, 1994; 15: S131-41). It’s worthwhile noting that the soldiers who were most badly affected by the swine flu outbreak of 1976 were just beginning their basic combat training, a time of exceptional exertion (J Infect Dis, 1977; 136: S363-8).

* Stress

– High stress levels probably have the single most important influence over the state of the immune system (J Fla Med Assoc, 1993; 80: 409-11). This was shown in a study where the participants – half of whom were proven to have high stress levels, the other half with low stress levels – were all exposed to rhinoviruses, the viruses responsible for the common cold. Only 27 per cent of those in the low-stress group developed symptoms, compared with 47 per cent of the high-stress group (N Engl J Med, 1991; 325: 606-12).

* Prescription drugs

– You are much more likely to develop the flu if you are taking a prescription drug. Antibiotics can enhance flu susceptibility (J Am Med Assoc, 1997; 278: 901-4), including flucloxacillin (Med J Aust, 1989; 151: 701-5) and Septrin (trimethoprim, sulphamethoxazole) (Br J Dermatol, 1987; 116: 241-2).

* Homeopathy
In France, where homeopathy is firmly established, the two most popular flu remedies are both homeopathic preparations: Oscillococcinum 200 and L.52 Lehning.

-Oscillococcinum, a combination of Anas Barbariae, Hepatis and Cordis, has been shown to be an effective antidote against the worst symptoms of flu, such as coughing, fever, shivering, and muscle and joint stiffness (Br J Clin Pharmacol, 1989; 27: 329-35).

– L.52 Lehning, a combination comprising 10 active homeopathic ingredients, has been proven to be more effective than a placebo (Casanova PA et al. L.52: A Flu Treatment, by Dr Ph Lecocq. Metz: Editions Lehning, 1988).

Bryan Hubbard

According to the UK’s Public Health Laboratory, the laurel wreath should go to an effective vaccination programme. Certainly, the rates of Hib have fallen dramatically; in both 1994 and 1995, only one case a year was reported in Oxford where 63 cases were previously reported every year. Similarly, just eight cases of Hib in children under the age of 5 from five other regions were seen in the nine months from October, 1994, compared to 270 and 269 cases in similar periods in 1990 and 1991.

So successful has been the campaign, say the experts, that no booster shot is needed when the child is aged 2.

Unfortunately, there is one niggling statistic that deserves to be heard. Of the 164 cases reported in the year from October 1992, 43 were true vaccine failures and, of these, 31 had had the prescribed three shots.

So is the vaccine really so effective after all or is medicine trying to take credit for a cyclical downturn in a disease, as other experts have suggested (The Lancet, 1997; 349: 1197-1201).

A similar sound of back slapping can be heard in the US, where they say the statistics back up their policy of a two dose measles immunization campaign, with the second dose given at school entry.

Experts from the Mayo Vaccine Research Group reckon that 98 per cent of children had measles antibodies after two vaccinations. But, again, there are always the niggardly statistics to spoil the party. In this case, 130 children who had no measles antibodies after the first shot were reimmunized, and this time 106 of them had developed antibodies six weeks after the jab. But this left 24 or 18.5 per cent who obstinately remained without immunity. Interestingly, the age of the child seemed to affect the outcome those aged under 13 months when they had the second jab were less likely to develop antibodies (JAMA, 1997; 277: 1156-8).

For more information, see WDDTY’s Vaccination Bible.

To determine the highest risks for Haemophilus influenzae b (or Hib), one of three causes of bacterial meningitis, which is epidemic in America, the Centres for Disease Control in Atlanta, Georgia, studied 92 licensed day care centres (creches, or nursery schools in Britain).

According to their results, recently published in the American Journal of Public Health, the disease was most likely to occur where personnel used towels or handkerchiefs to wipe children’s noses, had a “liberal faecal policy”, ie, admitted children who were not toilet trained or had diarrhoea, and were for profit centres admitting children mostly of the same age.

Haemophilus influenzae is one of several diseases commonly occurring in American day care facilities, which largely cater for pre school children, primarily in children under two.

Meanwhile, the 1 May issue of MIMSmagazine notes that plans are going ahead to introduce the haemophilus influenzae shot into the vaccination schedule this year, even though results of tests in Alaska have been disappointing.

More evidence casting doubt on the usefulness of vaccination against meningitis has emerged in research by the Haemophilus Influenzae Study Group (JAMA, 13 January 1993). In a study generally extolling the virtues of the Hib vaccination in cutting the number of meningitis cases, the group concedes that a “substantial” fall also occurred in children who hadn’t been vaccinated: down from 99.3 per 100,000 in 1989 to 68.5 per 100,000 in 1990. This particular drop, they add, is “consistent with previously identified cyclic variation in meningococcal disease incidence” that is, the disease reaches a peak and then goes into decline over a number of subsequent years.

“Although the reason for this cyclical variation is not known, it raises the possibility that the observed variation in meningococcal disease rates may not represent an effect of changes in medical therapy or diagnosis.”

SmithKline Beecham is to continue producing vaccines which contain the Urabe mumps virus strain which has been linked with cases of meningitis. In September last year (WDDTY, vol 3 no 8) the UK Department of Health announced that it was to stop using combined measles, mumps and rubella vaccines which contained the Urabe strain because of the meningitis risk. SmithKline has decided, however, to “continue to produce and supply vaccines that contain the Urabe mumps strain, so that existing immunization programmes in areas where no alternative mumps vaccine is available need not be suspended” (The Lancet, 2 January 1993).

The US Food and Drug Administration has approved an inactivated Japanese encephalitis vaccine (JE-VAX) for use by travellers to Asia (JAMA, 20 January 1993).

Our panel member, former Food and Drug Administration vaccine expert J Anthony Morris, tells us that side effects have occurred in 10 per cent of JE-VAX recipients everything from fever, vomiting and pain to swelling in the arms, legs and joints,and respiratory distress. “Given the opportunity to read and to understand the information in the package insert, the chances are great that the conclusion will be reached that it is in the interests of potential vaccine recipients to avoid not only mosquitoes [which carry the disease] but also the vaccine,” he said.

These findings by a Birmingham, UK, research team put a question mark over the annual ritual of having a jab as protection from the latest “killer” virus.

This groundbreaking research, based on elderly populations in England and Wales over four winters, reveals the lack of proper post mortem analysis among the elderly.

Doctors are too ready to blame an elderly person’s death on the latest flu strain when it was as likely to have been caused by respiratory syncytial virus (RSV).

More significantly, it indicates that the elderly require specialist care and treatment rather than visiting their family doctor with what they think is flu.

Dr D M Fleming, head of the Birmingham Research Unit that carried out the study, points out that the findings also make impossible any useful analysis of the effectiveness of the flu vaccines.

The study explains that RSV is most likely to be spread in cold and damp conditions a typical British winter, in fact. Countries in continental Europe often experience far colder, but drier, winters than Britain, and yet report lower death rates during the season. Increasing air pollution can also exacerbate RSV.

The study team says that RSV peaks at the beginning of the year, while December tends to be the worst time for flu.

By studying all deaths in England and Wales among the over 65s, they discovered that the number of deaths caused by the influenza A and B strains varied during the four years, whereas the numbers of RSV victims each year remained constant, again making it possible to isolate the deaths due to flu.

The vaccine, being offered to infants at two, three and four months, is supposed to protect against Hib caused meningitis.

However, the study by the National Centers for Disease Control in Atlanta, Georgia, of 10,400,000 children, showed that the “polysaccharide” version of the vaccine offered protection in 64 per cent of cases and the new “conjugate” vaccine, only 74 per cent protection.

Nine of 75 children with Hib disease had received the vaccine just two weeks before they became ill.

Originally developed to stop a host from rejecting an organ transplant, the drug is now being used for all manner of autoimmune illness.

The New England Journal of Medicine, 18 June 1992.