Intended for healthcare professionals

Search all rapid responses

All rapid responses

Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles.

Re: How covid-19 has exacerbated LGBTQ+ health inequalities Callum Phillips. 372:doi 10.1136/bmj.m4828

Dear Editor

I thoroughly welcome this article on the impact of Covid-19 and its impact on people from the LGB&T communities (Phillips 2021). This is an area that deserves much more attention.

In a recent systematic review in this area (submitted for publication), I and colleagues were distressed to find no fully published information on this from any of the large UK Covid-19 surveys, and no data at all on incidence, hospitalisations or deaths. For example, the UCL study into the psychological and social effects of Covid-19 in the UK (led by Prof Fancourt) omitted to collect data on sexual orientation and gender identity. The Office for National Statistics (ONS) validated a measure of sexual orientation over 10 years ago, which could easily have been used if they had just wanted to include that instead of both. I do not understand how a study on psychological and social impacts could miss out these key drivers.

Professor Sir Ian Diamond has agreed that incidence, hospitalisations and deaths in LGBT people is an important issue, and that the ONS fully supports discussions to attempt to understand these important questions. However, this topic seems to be so far down the SAGE list of priorities that we may not see data any time soon. Professor Sir Michael Marmot, the Health Inequalities expert, only mentions LGBT mental health issues in his Covid-19 review, and omits to mention the complete lack of data on incidence, hospitalisations and deaths in LGBT people.

The Women and Equalities Select Committee Report, as mentioned in the article by Phillips (2021), recommended that "In line with ethnicity monitoring, sexual orientation monitoring should be made mandatory across all NHS and state social care providers within the next 12 months" and that "Monitoring both sexual orientation and gender identity is far too important to be an aspiration rather than a concrete goal with clear timelines for delivery. The NHS needs to understand where the disparities are in order to formulate strategies to tackle them." . We know that there are some UK datasets which collect sexual orientation, for example the Health Survey for England, the Improving Access to Psychological Therapies (IAPT), Understanding Society, the UK Longitudinal Household Study, and there is sexual behaviour in Biobank. Surely one of these could be used to generate some sexual orientation data at least? Anything would be better than nothing, as I fear that no news is definitely not good news.

1. Marmot M, Allen J, Goldblatt P, Herd E, Morrison J. (2020). Build Back Fairer: The COVID-19 Marmot Review. The Pandemic, Socioeconomic and Health Inequalities in England. London: Institute of Health Equity

Competing interests: I am currently a member of the government LGBT Advisory Panel. This response is made in my academic capacity and not as part of the Panel.

18 March 2021
Catherine Meads
Professor of Health
Anglia Ruskin University
Cambridge
Re: The future of public health in England Sian M Griffiths, Tony Jewell, Maggie Rae, Jeanelle de Gruchy. 372:doi 10.1136/bmj.n662

Dear Editor
The editorial on the current state of public health and the future needs of the country is an accurate analysis.(1) It is of note that it has been produced by four leaders in the field who are highly qualified and have distinguished public health records. If the UK government is committed to improving the nation’s health and reducing inequalities then it should take heed of the recommendations in this excellent editorial.

We agree that directors of public health and their multidisciplinary teams have made heroic efforts during the pandemic and have provided support to many sectors, including schools, workplaces and local communities. Their profile in the public’s mind has increased significantly. Moreover, they have undertaken this work with inadequate resources.

Now, and in the future, the UK faces substantial health challenges but we believe that directors of public health and their teams have the potential to meet these challenges provided they are given the power and resources.(2-4) A multi-year settlement for public health is required. There are of course lessons from history - significant health gains were achieved when public health investments were made.(5-9)

For decades our universities have organised some excellent postgraduate public health and health promotion courses. High calibre professionals have been, and are being produced, but the evidence from the recent pandemic suggests that their expertise is not being sufficiently used.

Public health practitioners should lead responses to immediate health crises, for example communicable diseases, and the vital and diverse area of non-communicable diseases.(10) They should also play a leading role in health service reforms.(10) Here we believe that changes should not just focus on containing costs but should have the clear aims of reducing inequalities and improving population health.

Primary care is the cornerstone of the health service although its considerable potential to promote the health of individuals and communities has never truly been tapped.(11-14) Public health practitioners should be given the resources to foster health promoting approaches and to encourage doctors and nurses with existing skills, to make full use of them in primary and also secondary care.

At a national level with the demise of Public Health England a new independent organisation is needed to lead on improving health to complement the National Institute for Health Protection.(15) It would drive forward actions to target non-communicable diseases and the underlying issue of inequalities. Within this organisation senior positions should be filled with elite professionals who are qualified and skilled and have extensive experience of public health.

To create vision and provide guidance a new positive health strategy is needed with three important goals: to lengthen lives, improve the quality of lives, and ensure that no one is left behind.(16-18) The Faculty of Public Health, Association of Directors of Public Health and the Institute of Health Promotion and Education are well placed to advise and facilitate such a strategy.

Funding is a crucial issue. Successive governments have failed to provide an effective response to health inequalities and improving health.(2-4) We now need investment for the long term at local, regional and national levels. With a reinvigorated public health system, the country will be in a good position to promote the health of individuals and families and be far better prepared for future health crises.

References
1) Griffiths S M, Jewell T, Rae M, de Gruchy J. The future of public health in England BMJ 2021; 372 :n662 doi:10.1136/bmj.n662
http://www.gatorcrossfit.com/content/372/bmj.n662

2) Watson M C and Lloyd J. Need for increased investment in public health BMJ 2016;352:i761.
http://www.gatorcrossfit.com/content/352/bmj.i761

3) BMA. Funding for ill-health prevention and public health in the UK. May 2017.
http://bit.ly/2quLN3K

4) Watson M C and Thompson S. Government must get serious about prevention. BMJ 2018;360:k1279.
http://www.gatorcrossfit.com/content/360/bmj.k1279

5) CDC. Ten Public Health Achievements of the Twentieth Century - United States, 1900-1999. MMWR Weekly 1999;48(12):241–3
https://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm

6) Gray S, Pilkington P, Pencheon D, Jewell T. Public health in the UK: success or failure? J R Soc Med 2006;99: 107-11.
https://journals.sagepub.com/doi/abs/10.1177/014107680609900309

7) Watson M C and Errington G. Preventing unintentional injuries in children: successful approaches. Paediatrics and Child Health. 2016; 26(5), 194-199.
https://www.paediatricsandchildhealthjournal.co.uk/article/S1751-7222(15)00255-3/pdf

8) Watson M C and Cheater S. Lessons from history – public health successes. BMJ Rapid Response 09 September 2018.
http://www.gatorcrossfit.com/content/362/bmj.k3653/rr-2

9) Middleton J. Public health at 170. What’s needed now is a big birthday present. BMJ 2018;362:k3653
http://www.gatorcrossfit.com/content/362/bmj.k3653

10) Beaglehole R and Bonita R. Global Public Health. A new era. Oxford: oxford University Press, 2009.

11) Watson, M. Going for gold: the health promoting general practice. Quality in Primary Care. 2008; 16:177-185.
https://primarycare.imedpub.com/going-for-gold-the-health-promoting-gene...

12) House of Commons Health Committee. Primary care. Fourth Report of Session 2015–16. HC 408. London: HOC, 2016

13) Watson M C and Lloyd J. Pressure on general practice in England. Time to put GPs first by investing in general practice. BMJ 2019;365:l4158
http://www.gatorcrossfit.com/content/365/bmj.l4158

14) Watson M C and Jeavons C. Primary care under threat: time for the Government to address the urgent challenges. BMJ Rapid Response 11 October 2020.
http://www.gatorcrossfit.com/content/371/bmj.m3793/rr-0

15) Watson M C, Tilford S. Health promotion is at a crossroads with the demise of Public Health England. BMJ 2020; 370 :m3750 doi:10.1136/bmj.m3750
http://www.gatorcrossfit.com/content/370/bmj.m3750

16) Jacobson B, Smith A, Whitehead M. The nations' health-a strategy for the 1990s. London: King Edward's Hospital Fund for London, 1991. (Revised ed.)

17) Galea S. Well. What We Need To Talk About When We Talk About Health. Oxford: Oxford University Press, 2019.

18) Watson M C, Owen P. Inequalities in 2020: time for a health strategy that unites the country BMJ 2020; 368 :m544 doi:10.1136/bmj.m544
http://www.gatorcrossfit.com/content/368/bmj.m544

Competing interests: No competing interests

18 March 2021
Michael Craig Watson
Trustee, Institute of Health Promotion and Education.
Professor Sylvia Tilford, Vice President, Institute of Health Promotion and Education.
Institute of Health Promotion and Education, PO Box 7409, Lichfield WS14 4LS, UK. http://ihpe.org.uk/
Re: Do not routinely offer imaging for uncomplicated low back pain Amanda M Hall, Kris Aubrey-Bassler, Bradley Thorne, Chris G Maher. 372:doi 10.1136/bmj.n291

Dear Editor

The general message from the recent BMJ article (1) advises strongly against unnecessary imaging using either X ray, CT or MRI in non specific low back pain patients claiming that it is potentially harmful and of course more expensive. This is based on two systematic reviews which include a total of 6 randomised controlled trials and several observation studies. There is no doubt that imaging in LBP is overused and misused in primary care settings.

In researching this response I found one study by Maher (2) looking at the factors leading to selection of MRI which concluded that in 35% of patient requests there were no red flags and in 32% no suspicion of pathology, but also found that in 66% of patients who did have red flags no imaging was requested! Furthermore 61% of patients with clinically suspicious pathology were not sent for MRI.

This suggests that the main problem we have is lack of training of doctors in all clinical settings. Not whether they have read the guidelines but can they examine the patient thoroughly enough to perform effective triage, hone the application of imaging, interpret the clinical relevance of these findings based on history and proper examination and adequately treat and reassure patients.

This BMJ article is probably more relevant to other private healthcare systems where there may be financial incentives to over investigate and treat, than the UK. In most parts of the UK GPs do not have direct access to X Rays of the low back or indeed MRI. Most emergency departments do not have ready availability of MRI and rarely if ever X ray patients with acute low back pain unless there is a history of trauma or serious red flags. It has long been established that plain X rays to investigate lumbar spine disorders is fairly useless, but limited sequence MRI or full sequence MRI can be helpful at least in the appropriate 5- 10% of patients as indicated in the very first bullet point of this article.

X rays of course do provide harmful radiation which is why I'm surprised to see chiropractic care recommended for non specific low back pain when it is such common practise for chiropractors to take X Rays of their patients, sometimes including the whole spine and pelvis.

This article seems to rely quite heavily on several observational studies which overall provide low quality evidence that early MRI leads to higher costs due to more treatment. However in these studies it is not clear what the driver to early MRI is. It is possible the degree of pain and anxiety influences physician choice. Such patients whether they have scans or not will tend to receive more treatment whether it be physical therapy, injection therapy or surgery. MRI might simply be a surrogate for pain and anxiety rather than a cause of higher indirect costs and is therefore not the pivotal issue.

However there is a serious conceptual problem here. Non specific LBP means we don’t know what is wrong, and this article is full of admissions that we don’t know. But we’re advised to tell our patients - it’s a simple strain or sprain?

50% of acute onset LBP occurs spontaneously. Mr Smith wakes up in the morning and he cannot get out of bed, let alone go to work. What has he been doing overnight to sprain his back?

Sprain implies damaged ligaments and take several weeks to heal and are visible on MRI of the ankle. According to this article non specific LBP is invisible!

Once again the experts and economic watchdogs are advising doctors and patients to accept ignorance and ignore repeatedly the growing evidence that we can work out the problem.

If patients with chronic LBP are referred to an appropriately trained spinal physician the source of pain can be found in 70% of LBP patients (3-6). We can give a proper explanation of the patient’s pain by using diagnostic blocks of the likely structural pain sources (disc, facet joint, sacroiliac joint, vertebral end plate, etc) together with clues from MRI. For example, Albert has shown that 30% of CLBP patients have Modic 1 vertebral changes which are treatable (7). The High intensity zone in a posterior annular tear is a marker for discogenic pain (8). Synovial effusions in facet joints also show on MRI and respond to injection and RF denervation. In fig 2 of this article the decision algorithm recommends MRI is only useful if patient is a candidate for surgery. This seems to be putting the cart before the horse – no patient is considered for surgery without an MRI which correlates with clinical features. Besides surgery, MRI can help plan targeted interventions such as image guided transforaminal injections, and the appropriate and safe level for interlaminar epidural steroid injection.

To summarise a more nuanced message might be that imaging can be misused, misinterpreted and result in misguided interventions. That’s not a problem with imaging per se but a problem in the eye of the beholder which can be corrected by wider reading of the published literature, less biased conclusions drawn from selected literature to draw up guidelines, and improved training in physical examination and imaging interpretation at all levels.

Dr John Tanner, MSK and Sports physician (john@ovingclinic.co.uk)

(1) Hall AM Aubrey-Bassler K Thorne B Maher CG Do not routinely offer imaging for patients with uncomplicated low back pain BMJ Feb 2021;372:n291
(2) Jenkins HJ Downie ASc Maher CG Magnussen J Imaging for low back pain: is clinical use consistent with guidelines? A systematic review and meta-analysis. The Spine Journal 18: (12) 2018, Pp 2266-2277.
(3) Schwarzer AC Wang SC Bogduk N Prevalence and clinical features of lumbar zygapophyseal joint pain: a study in an Australian population with chronic low back pain. Ann Rheum Dis 1995 54 (2): 100-106
(4) Schwarzer AC Aprill CN Derby R Fortin J The prevalence and clinical features of internal disc disruption in patients with chronic low back pain Spine 1995 20(17): 1878-83
(5) Schwarzer AC Aprill CN Bogduk N The sacroiliac joint in chronic low back pain Spine 1995 20(1): 31-37
(6) De Palma MJ Ketchum JM Saullo T What is the source of chronic low back pain and does age play a role? Pain Med 2011 (12): 224-33
(7) Albert HB Sorenson JS Christenson BS Manniche C Antibiotic treatment in patients with chronic low back pain and vertebral bone oedema (Modic Type 1 changes) : a double blind randomised controlled trial of efficacy; Eur Spine J 2013 22; 697-707
(8) O’Neill C Kurgansky M Kaiser J Lau W Accuracy of MRI for diagnosis of discogenic pain; Pain Phys 2008 (11) 3: 311-26

Competing interests: No competing interests

17 March 2021
john a tanner
Musculoskeletal physician
BASEM, Pain Society, SPine intervention Society, BMA
Oving Clinic, Oving
Re: Covid-19: EU looks to speed up vaccine rollout Rory Watson. 372:doi 10.1136/bmj.n730

Dear Editor,

Having read Rory Watson's article with great interest, I'd like to question his figures for France, where he wrote: "Overall, 9% of people over 18 have received their first dose. But, while countries such as Denmark, Greece, Lithuania, and Poland had used almost all of their deliveries, France and Germany had administered just over two thirds of theirs and Luxembourg only 58%."

As of March 15, France has administered 80.8% of the vaccines 'received or officially expected'.

Source: https://covidtracker.fr/vaccintracker/ (based on figures from the Ministry of Health)

Regards,
Peter van Balen
France

Competing interests: No competing interests

17 March 2021
Peter van Balen
retired
France
Re: Covid-19 vaccine hesitancy among ethnic minority groups Mohammad S Razai, Tasnime Osama, Douglas G J McKechnie, Azeem Majeed. 372:doi 10.1136/bmj.n513

Dear Editor,

Vaccine hesitancy and resistance has been reported among people and healthcare staff from ethnic minorities (1). This is a serious concern given covid-19 is the largest global public health challenge in recent years. Covid-19 vaccination offers hope in preventing covid related morbidity and mortality and helps to build community immunity.

The month of fasting, Ramadan, globally this year spans April to May 2021. People from some ethnic minority backgrounds such as Pakistani, black, and Bangladeshi will commence fasting but these groups are hesitant to receive a covid-19 vaccine (1). They may be more hesitant because they don’t want to compromise their fast: often seen as a religious obligation. It is therefore important for these groups of people to know that having vaccines, especially one of the covid-19 vaccines at first or second dose, through the intramuscular route does not nullify one’s fast and vaccination should not be delayed (2).

It is crucial to reassure people and healthcare staff that receiving a covid-19 vaccine within fasting time (from dawn to dusk) does not break the fast, and the fast remains intact. Internationally healthcare advocates and leaders need to work with Muslim faith leaders to disseminate this. Fasters may also be concerned that potential side effects of covid-19 vaccination for example myalgia, headache, and tiredness may make it difficult to maintain their fast. Clinicians and covid-19 vaccinators can advise fasters to drink more clear fluid and take simple analgesia outside of fasting times to mitigate side effects if needed.

References:

1) Razai MS, Osama T, McKechnie DGJ, et al. Covid-19 vaccine hesitancy among ethnic minority groups. BMJ 2021;372:n513
2) British Islamic Medical Association. Fasting and Covid Vaccinations. 2021.

Competing interests: No competing interests

17 March 2021
Faraz Mughal
General practitioner and NIHR Doctoral Fellow
School of Medicine, Keele University, ST5 5BG, United Kingdom
Re: Covid-19: Highest death rates seen in countries with most overweight populations Jacqui Wise. 372:doi 10.1136/bmj.n623

Dear Editor

I think it is time for researchers to follow the lead I offered in my blog of 1st May 2020, which I reproduce here:

"On briefly to obesity, another apparent risk factor. There may be a simple answer (also explaining why diabetes is another risk). I wrote a limerick:

There’s an interesting hormone called leptin,
One can measure it – fat cells it’s kept in.
It may have a role
In RA – as a whole
It’s a test we are not yet adept in.

Some years ago I read an article about how leptin might be involved in the inflammation of rheumatoid arthritis, hence the verse. I quote from a definitive article about leptin (for the whole thing see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2829991/ where you will find lots of lovely references).

“Leptin is one of the most abundant adipocytokines produced by adipocytes, together with cytokines such as tumor necrosis factor (TNF)-α, IL-6, IL-1, the CC-chemokine ligand 2 (CCL2) and other mediators.
Leptin has pro-inflammatory properties and several actions similar to those of the acute phase reactants, and upregulates the secretion of inflammatory cytokines like TNF-α, IL-6, and IL-12.” .

Obese folk have more fat cells: “obese individuals typically produce higher levels of leptin than leaner individuals, yet obese subjects are resistant to the inhibitory activity that this molecule has on food intake and on the control of satiety.” (from the same article). Obese folk have insulin resistance, so develop diabetes. Put two and two together; there’s more circulating leptin, so more likelihood that inflammatory cytokines are upregulated, so when a further upregulating trigger comes along, such as Covid-19, then levels will be even higher once the storm begins.

I may be wrong. But it seems a reasonable hypothesis to me.

So as well as measuring oxygen saturation and ferritin to look for early signs of a storm, maybe we should also be boosting vitamin D levels, especially in BAME subjects, and checking leptin levels in the overweight. It is of course interesting that one Italian group has found that their patients with inflammatory arthritis on cytokine blockers do not seem to be dying from Covid-19 meltdown. Could it just be that the lockdown of their TNF, IL-1 and IL-6 stops the storm? No doubt time will tell!"

Although I have suggested that leptin may be important several times since it would appear that no-one has looked into it. Having flagged the hypothesis in a letter to the "Annals of Internal medicine" back in August 2020 I am at least pleased to see that they are publishing it in print - as from February 2021. Someone might make a name for themselves by proving the hypothesis; just a nod to me will be fine.

Competing interests: No competing interests

17 March 2021
Andrew N Bamji
Retired consultant rheumatologist
None
Rye
Re: Seven days in medicine: 3-9 March 2021 . 372:doi 10.1136/bmj.n648

Dear Editor

What a difference a day (or three) makes!

Today (17th March) the Secretary of State suggests that, far from there being a surge in vaccine provision, there may be a cutback. He did not explain why, but we have had the unedifying spectacle of the EU once again threatening to restrict the export of vaccines.

I have long espoused (or should that be exposed?) the practice of oxymoronic medicine. We have, on the one hand, the EU President threatening to stop exports of EU produced AstraZeneca vaccine which member states have suddenly taken fright over, thanks to a failure to understand relativity in relation to thrombotic risk, and therefore do not want. We are also told that because of this, large quantities of the vaccine that are available for use in the EU are being wasted.

I find this rather difficult to understand. They are unhappy about using the vaccine; their populations don't want it because they are afraid of it, but they wish to stop it being exported. Discuss, preferably on one side of A4.

Competing interests: No competing interests

17 March 2021
Andrew N Bamji
Retired consultant rheumatologist
Rye
Re: The EMA covid-19 data leak, and what it tells us about mRNA instability Serena Tinari. 372:doi 10.1136/bmj.n627

Dear Editor

We have read the article “The EMA covid-19 data leak, and what it tells us about mRNA instability” [1], published in BMJ on 10/03/2021 with steadily growing concern.

This article questions an EMA decision, and this criticism is based on data unlawfully obtained from EMA. While EMA should do everything to prevent data leaks, computer hacking is a criminal offence. EMA states that the information was partially doctored, and that the perpetrators selected and aggregated data from different users and added additional headings [2]. The data published on the dark web are not verifiable, extremely questionable and thus, the propagators of such information should not be provided with a legitimate platform.

It is unclear to us why a respected journal chose to present unverifiable information, in the process damaging an institution that has worked for 25 years in a transparent and successful manner. Evaluation of new medicinal products is difficult; it requires competence, and it takes time to go through all the information supplied by applicants. Therefore, it is part of the procedure and perfectly acceptable that after the first reading, the authorities pose numerous questions to applicants. However, the responses to these questions, which were adequate to reassure the regulator as reported in the public assessment report [3], have not been taken into account in the BMJ article. Besides, EMA is not the only regulatory authority which has looked at these data. The vaccine has been approved and is now in use in more than 40 countries, including many European countries but also Australia, Canada, the United States, Chile, Singapore and a number of Middle Eastern countries.

We now have data on the use of the Pfizer-BioNTech vaccine in a real-world setting. In the UK, data from the SIREN study, a prospective cohort study among staff working in publicly funded hospitals, were used to determine vaccine effectiveness of the vaccine. The study demonstrates that the vaccine effectively prevents both symptomatic and asymptomatic infection in working age adults [4]. Similarly, all newly vaccinated persons in Israel during the period from December 20, 2020, to February 1, 2021, were matched to unvaccinated controls. Estimated vaccine effectiveness at 7 or more days after the second dose was higher than 90% for all outcomes assessed, including documented infection, symptomatic Covid-19, hospitalization, and severe disease [5]. In the US, where tens of millions of doses of the Pfizer vaccine have been administered, a retrospective cohort analysis of a high-risk population, residents of skilled nursing facilities, found that even with partial vaccination, Pfizer-BioNTech COVID-19 vaccine provided protection to the residents [6].

We believed that the BMJ promotes Evidence-Based Medicine, and would only publish articles based on hard, verifiable data. We can only imagine that this editorial somehow escaped your vigilance and professional scrutiny.

Sincerely yours,

Pieter Neels, International Alliance for Biological Standardization - IABS, Geneva, Switzerland

Elizabeth Miller, Department of Infectious Disease Epidemiology, Faculty of Epidemiology & Population Health London School of Hygiene & Tropical Medicine, United Kingdom

Pierre Van Damme, Centre for the Evaluation of Vaccination, Vaccine & Infectious Diseases Institute, University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium.

Joris Vandeputte, International Alliance for Biological Standardization - IABS, Geneva, Switzerland

Thomas Verstraeten, P95 Epidemiology & Pharmacovigilance, Leuven, Belgium

Albert Osterhaus, University of Veterinary Medicine, Hannover, Germany

Steffen Thirstrup, Affiliate Professor, Department of Drug Design and Pharmacology, Translational Pharmacology Faculty of Health, University of Copenhagen, Denmark

Marc Baay, P95 Epidemiology & Pharmacovigilance, Leuven, Belgium

Stanley Plotkin, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, United States

1. Tinari S. The EMA covid-19 data leak, and what it tells us about mRNA instability. Bmj 2021;372:n627. doi: 10.1136/bmj.n627 [published Online First: 2021/03/12]
2. European Medicines Agency. Cyberattack on EMA - update 6 2021 [Available from: https://www.ema.europa.eu/en/news/cyberattack-ema-update-6March 15, 2021.
3. European Medicines Agency. Comirnaty - COVID-19 mRNA vaccine (nucleoside-modified) 2020 [Available from: https://www.ema.europa.eu/en/medicines/human/EPAR/comirnatyMarch 15, 2021.
4. Hall VJ, Foulkes S, Saei A, et al. Effectiveness of BNT162b2 mRNA Vaccine Against Infection and COVID-19 Vaccine Coverage in Healthcare Workers in England, Multicentre Prospective Cohort Study (the SIREN Study). Lancet preprint 2021 doi: http://dx.doi.org/10.2139/ssrn.3790399
5. Dagan N, Barda N, Kepten E, et al. BNT162b2 mRNA Covid-19 Vaccine in a Nationwide Mass Vaccination Setting. N Engl J Med 2021 doi: 10.1056/NEJMoa2101765 [published Online First: 2021/02/25]
6. Britton A, Jacobs Slifka K, Edens C, et al. Effectiveness of the Pfizer-BioNTech COVID-19 Vaccine Among Residents of Two Skilled Nursing Facilities Experiencing COVID-19 Outbreaks — Connecticut, December 2020–February 2021. Morb Mortal Wkly Rep 2021;ePub: 15 March 2021 doi: http://dx.doi.org/10.15585/mmwr.mm7011e3

Competing interests: PN is a regulatory consultant and is working with a number of COVID-19 developers of vaccines and antibodies. PVD declares organisational financial interest, through research grants to the University of Antwerp for the conduct of COVID19 vaccine trials. TV is the managing director of P95, who has received consulting fees from mRNA vaccine manufacturers. ST is a former member of CHMP, now working as a regulatory consultant. MB is an employee of P95, who has received consulting fees from mRNA vaccine manufacturers. SP is a paid consultant to numerous companies developing vaccines against COVID-19, including Moderna but not Pfizer. Other authors declare no competing interests.

17 March 2021
Pieter Neels
Consultant
Elizabeth Miller, Department of Infectious Disease Epidemiology, Faculty of Epidemiology & Population Health London School of Hygiene & Tropical Medicine, United Kingdom; Pierre Van Damme, Centre for the Evaluation of Vaccination, Vaccine & Infectious Diseases Institute, University of Antwerp, Universiteitsplein 1, 2610, Wilrijk, Belgium. Joris Vandeputte, International Alliance for Biological Standardization - IABS, Geneva, Switzerland; Thomas Verstraeten, P95 Epidemiology & Pharmacovigilance, Leuven, Belgium; Albert Osterhaus, University of Veterinary Medicine, Hannover, Germany; Steffen Thirstrup, Affiliate Professor, Department of Drug Design and Pharmacology, Translational Pharmacology Faculty of Health, University of Copenhagen, Denmark; Marc Baay, P95 Epidemiology & Pharmacovigilance, Leuven, Belgium; Stanley Plotkin, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, United States
International Alliance for Biological Standardization
Zoersel, Belgium
Re: Domestic violence during the pandemic Gene Feder, Ana Flavia Lucas d’Oliveira, Poonam Rishal, Medina Johnson. 372:doi 10.1136/bmj.n722

Dear Editor,
Domestic violence costs 8 trillion dollars every year, more than wars. Apart from personal, family, social issues, there also exists huge economic impact.
References
https://www.reuters.com/article/us-abuse-costs-idUSKBN0H41AL20140909
https://www.weforum.org/agenda/2014/09/domestic-violence-cost-war-develo...
https://www.huffpost.com/entry/domestic-violence-8-trillion-a-year_b_707...

Competing interests: No competing interests

17 March 2021
Stavros Saripanidis
Consultant in Obstetrics and Gynaecology
Thessaloniki, Greece
Re: Covid-19: European countries suspend use of Oxford-AstraZeneca vaccine after reports of blood clots Jacqui Wise. 372:doi 10.1136/bmj.n699

Dear Editor
I agree with Mr Stone.
Dr Badrinath and his colleagues have recently invoked the memories of Dunkirk .He and those of his ilk would like us, the public, to just obey orders .
Not I. Would await Martial Law and then a Court Martial .
Perhaps Dr Badrinath would care to study British Social History?

Competing interests: I feel the Government and its officers - even doctors - are unwilling to accept that at least some members of the public are intelligent enough to be able to see when the officialdom is pushing us to accept Govt versions without critical evaluation.

17 March 2021
JK Anand
Retired public health physician
Free spirit
Peterborough

Pages

国产狠狠狠的在啪线香蕉,免费观看日本黄免毛片,一本大道香蕉久在线播放29