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

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

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.

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