SPIEGEL-TALK "Longing for the Pandemic"

Epidemiologist Tom Jefferson on false prophecies of influenza experts, the overestimated effect of vaccination and the great benefit of hand washing By Johann Grolle and Veronika Hackenbroch 19.07.2009, 13.00 – from DER SPIEGEL 30/2009
Jefferson, 55, has worked for the Cochrane Collaboration for 15 years. With an international team of scientists, the doctor evaluates all published studies on influenza. Before that, Jefferson, who now lives near Rome, was a GP in the British Army for ten years.
SPIEGEL: Mr Jefferson, the world is living in fear of swine flu. Already in autumn, experts say, one in three people worldwide could be infected with the new H1N1 virus. How do you protect yourself and your family?
Jefferson: I wash my hands as often as possible – although I’m not so much concerned about swine flu. Washing your hands is probably the best protection against not only influenza, but most other respiratory and gastrointestinal infections
SPIEGEL: So swine flu is not particularly worrying you?

Jefferson: It is true that influenza viruses are sometimes unpredictable. A certain amount of caution is therefore called for. Nevertheless, I find it crazy what disasters are predicted for us year after year by the influenza experts. These prophecies get worse and worse. Yet none of them has ever come true. For example, what happened to the bird flu that was supposed to kill us all? Nothing. But these people still go on and on with their predictions. Sometimes it seems to me that some people are just longing for a pandemic.

SPIEGEL: Who do you mean? The World Health Organization WHO?
Jefferson: The WHO as well as the health authorities, the virologists, the pharmaceutical industry. Over the years, a whole machine has been built up around this idea, this idea of the impending influenza pandemic. A lot of money, influence, careers, entire institutions are attached to it! All that was needed now to set this machinery in motion was a small, mutated virus.
SPIEGEL: On your Italian homepage there is a “pandemic countdown” that expires every year on 1 April. Doesn’t the situation call for something more serious?

Jefferson: I’m just skewering the false certainty that we’re being led to believe. Will a third of the world’s population get swine flu? Nobody knows that at the moment. But even if they do, I don’t see, at least at the moment, any difference in principle to a normal wave of influenza. Perhaps swine flu would have gone unnoticed until today if it were not an influenza virus but another, unknown virus.

SPIEGEL: Has the WHO declared a pandemic prematurely?
Jefferson: Don’t you find it remarkable that the WHO changed its pandemic definition specifically for this? The criterion that it must be a disease with high mortality was simply deleted. Only then did swine flu become a pandemic.
SPIEGEL: But every year there are 10,000 to 30,000 influenza deaths in Germany alone. Influenza is the deadliest infectious disease in the western world…

Jefferson: Wait a minute! These numbers are nothing but estimates. But first and foremost, you have to distinguish between influenza-like infections and true influenza. The symptoms – sudden high fever, aching limbs, respiratory symptoms, possibly bronchitis and pneumonia – are the same for both. But only true influenza is actually caused by influenza viruses. influenza-like infections, on the other hand, are caused by over 200 different pathogens. However, the figures for so-called influenza deaths always include deaths caused by all these other pathogens. If an old person dies of pneumonia, no one takes a throat swab to find out whether it was actually a real influenza virus that killed him. On average, only seven percent of influenza-like infections are actually caused by influenza viruses. The importance of these viruses is systematically overestimated.

SPIEGEL: And the 200 other types of viruses?
Jefferson: Researchers are far too little interested in them! Rhinoviruses, for example, come in more than a hundred varieties. They usually only cause a normal cold – but they can also be fatal. The so-called RS virus, on the other hand, is particularly dangerous for infants and small children.
SPIEGEL: So why aren’t researchers interested in it?
Jefferson: Quite simply, rhinoviruses, RS viruses and most other of these pathogens do not make big money and hardly any career. Against influenza viruses, on the other hand, there is a vaccine and also drugs. The big money of the pharmaceutical industry is behind this! They also make sure that research on influenza is published in good journals. That way it gets more attention and the whole field of research becomes interesting for ambitious scientists.
SPIEGEL: So scientifically, the great interest in the influenza viruses is completely unfounded?

Jefferson: Limiting it to influenza is not only wrong, it’s actually very dangerous. Do you remember SARS? That was a really dangerous epidemic. It came fast like a meteor and many people died. SARS took us by surprise because it was caused by a completely unknown coronavirus. Where did this virus come from? Where did it disappear to? Or is it still there? We still don’t know all that. And every year new, strange pathogens are discovered. For example, the bocavirus, which can cause bronchitis and pneumonia in small children. Or the so-called metapneumovirus, which in studies was responsible for more than five percent of influenza-like illnesses. We should remain vigilant in all directions!

SPIEGEL: But in the great pandemic of 1918/19, it was real influenza viruses that went around the world and killed up to 50 million people – or do you deny that too?

Jefferson: It’s quite possible that it was, but we don’t know for sure. The 1918/19 pandemic still puzzles us a lot. The H1N1 virus has only been considered the trigger for twelve years. But there are also indications that bacteria were involved. What remains unexplained, however, is above all why influenza mortality fell so dramatically after the Second World War. Today, it is only a fraction of what was the norm before the war. The later so-called pandemics, the “Asian flu” of 1957 and especially the “Hong Kong flu” of 1968/69, can hardly be recognised as outstanding events in the death statistics, if at all.
SPIEGEL: So why do people talk about pandemics at all?
Jefferson: You’ll have to ask the WHO that!
SPIEGEL: In your opinion, on what does it depend whether a virus like the swine flu virus, for example, becomes a global threat?

Jefferson: Unfortunately, all we can say is: we don’t know. I suspect that the whole thing is much more complex than we can imagine today. Perhaps Robert Koch’s postulate that a pathogen causes a disease falls short with all these viruses that produce influenza-like symptoms. Why, for example, don’t we get influenza in the summer? After all, the pathogens are there all year round! The German physician and hygienist Max von Pettenkofer developed a theory on this back in the 19th century, according to which the environment can change the disease through contact with the pathogen. I think it would be worthwhile to continue research in this direction. Then we could perhaps also better understand the pandemic of 1918/19 or assess the dangers of swine flu.

SPIEGEL: People are better prepared today than they were in 1918. Vaccine against swine flu should soon be available. Last week, the German government announced that it would buy enough of it for 30 percent of the population. How well do you think it will protect?
Jefferson: Only the serious case can show that. Before the vaccine is approved, it is only tested to see whether it causes an antibody reaction. But whether this is sufficient to actually protect against the disease?
SPIEGEL: Are you pessimistic?
Jefferson: (laughs) Let’s put it this way: We’ll know more in a year!

SPIEGEL: For years you have been systematically evaluating all studies on seasonal influenza vaccines for the Cochrane Collaboration. How well do they protect?

Jefferson: Not very well. An influenza vaccination can do nothing against the large number of influenza-like infections anyway, because it is only directed against influenza viruses. Therefore, the vaccination does not change anything about the increased overall mortality during the winter months. But even against influenza viruses, vaccination provides only moderate protection at best. Among other things, there is always the danger that the circulating influenza viruses change after the vaccine has been produced, so that in the worst case the vaccination becomes ineffective. At least the few good studies that exist show that vaccination works best in young, healthy adults. Children and the elderly, on the other hand, receive little or no benefit.

SPIEGEL: But it is precisely for these population groups that it is recommended!
Jefferson: You are absolutely right. That is one of the contradictions between scientific evidence and practice.
SPIEGEL: And how does this contradiction come about?
Jefferson: Of course, this has to do with the influence of the pharmaceutical industry. But it also has to do with the fact that the importance of influenza is completely overestimated. It’s about research money, about power, about influence, about scientific fame!

SPIEGEL: Is there any good reason at all to have a influenza vaccination?

Jefferson: I don’t see any. But it’s not for me to decide.
SPIEGEL: And what about Tamiflu and Relenza, the influenza drugs that are also used against swine flu? How well do these drugs actually work?
Jefferson: If you take them in time, they shorten the duration of the influenza by one day on average. One study also found that they reduce the risk of pneumonia.
SPIEGEL: Can these drugs reduce the mortality rate from influenza?
Jefferson: Quite possibly. But there is no scientific evidence of this yet.
SPIEGEL: And the side effects?
Jefferson: Tamiflu can cause nausea. And there is also evidence of psychiatric side effects. There are reports from Japan of acute psychotic symptoms similar to schizophrenia in young people who had taken Tamiflu.
SPIEGEL: Does the use of such means make sense at all then?
Jefferson: In severe cases, yes. But under no circumstances should Tamiflu be distributed to entire schools, as is happening now in some cases. So I’m not at all surprised that there are already reports of resistance to swine flu.
SPIEGEL: In Germany, every federal state is supposed to stockpile influenza medication for 20 percent of the population. Is that nonsense in your eyes?
Jefferson: At least there are much cheaper ways to achieve much more. For example, school children should be taught to wash their hands regularly. Preferably after every lesson! And a few hundred washbasins should be installed at every airport. Anyone who does not wash their hands after a flight will be stopped immediately by customs – invisible dyes in the water could make this possible. And wearing a mouth guard can also be useful.
SPIEGEL: Is it really proven that these measures help?
Jefferson: There are some good studies on this that were done during the SARS epidemic. They are so-called case-control studies. They studied people who had close contact with the SARS virus. They then compared the behaviour of those people who had been infected during this contact with the behaviour of those who had not been infected. These studies have produced very clear results.
SPIEGEL: You sound downright enthusiastic!
Jefferson: I am too. The great thing about these measures is that they are not only cheap. They also help against more than just influenza viruses. Almost all 200 pathogens that cause influenza symptoms can be fought, as well as gastrointestinal viruses and even completely unknown germs! A study from Pakistan has shown that washing hands can save children’s lives. The Nobel Prize should be awarded for this!
SPIEGEL: Mr Jefferson, thank you for this interview.
The interview was conducted by the editors Johann Grolle and Veronika Hackenbroch.