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Five sensible evidence-based policies for swine flu

Carl Heneghan
Last edited 17th March 2010

It seems every day now there is new emerging information on swine flu and what we all should be doing that isn’t backed up by the evidence. Therefore, given no-one involved in policy seems to take a blind bit of notice of the evidence, I’m setting out my sensible evidence policies (SEP for short) for the way forward.

1) Wash your hands: in this week’s BMJ a systematic review by Tom Jefferson and colleagues report on Physical interventions to interrupt or reduce the spread of respiratory viruses. Many simple and low cost interventions reduce the transmission of epidemic respiratory viruses, of which, hand washing 10 times daily halves the spread of respiratory infections.

2) Where is the burden of proof for mass vaccination? It would seem straight forward that a mass vaccination programme is backed up by robust evidence. Well it isn’t. Again Jefferson’s work is important on this issue: Influenza vaccination: policy versus evidence. On the whole, systematic review evidence reveals inactivated vaccines have little or no effect; most studies are of poor methodological quality; there is also a paucity of evidence on the safety of these vaccines and reasons for the current gap between policy and evidence are at best unclear.

3) Antiviral should not be handed out to everyone: This is probable the most sensible policy and should be initiated hence forth. The benefits of these drugs are fairly limited. In children Neuraminidase inhibitors provide only a small benefit by shortening the duration of illness in children with influenza and have little effect on asthma exacerbations or the use of antibiotics. Their effects on the incidence of serious complications and on the current A/H1N1 influenza strain are unknown. Using antivirals liberally runs the risk of generating resistance. We have known this for donkey’s years; this is exactly what happened for antibiotics.

4) Extend primary care emergency out of hours into the day: from the echelons of health policy I have been given the reason why we continue with the current policy - there is no alternative strategy that they can think of to replace the current one. Emergency care in general practice normally starts at 6.30 pm and runs throughout the night. What we should do is extend this into the daytime, have one central practice for all suspected patients with influenza to be seen by clinicians. With the time saved in practice not seeing suspected cases (probably about 4 hours per practice per week) we could staff it with GPs at no extra cost and who could then sift out those with more severe disease and at greatest risk of complications. Not evidence based yet but sensible.

5) No school closures: The evidence for social distancing policies is at best weak and flawed, and the evidence to date we have on school closures is primarily based on modeling studies. School closure are commonly suggested as a containment strategy, yet there is no consensus on the scale of the benefits to be expected and models assume that there is a high rate of transmission (50%) occurring in schools, and children don’t mix when kept of school. Well I can tell you now, if my kids are off and I’m supposed to be at work I’ll palm them off on anyone who’ll have them. Also the economic cost per week is estimated to be between £0·2 billion and £1·2 billion; cost of a 12-week school closure may be as high as 1·0% of GDP.

There are my five - well four evidence-based and one sensible. If you have a policy to add to the SEP list then I’d be grateful to hear from you.

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