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Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on Although a selection of rapid responses will be included online and in print as readers' letters, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window. Letters are indexed in PubMed.

Re: Misdirected care in a misdirected world Kamran Abbasi. 358:doi 10.1136/bmj.j4256


Well said "Misdirected care in a Misdirected world".

the present era is Kali Yuga; Lord Krishna's departure marks the start of Kali Yuga and is associated with the demon Kali (not to goddess Kālī). There are four Yugas: they are called Satya Yuga, Treta Yuga, Dwapara Yuga and Kali Yuga. Human civilization degenerates spiritually during Kali Yuga, which is referred to as the Dark Age. People will be addicted to intoxicating drinks & drugs, and sin will increase (1,2).
According to Aryabhatta the mathematician and astronomer, Kali Yuga started in 3102 BCE (3).

The Crisis of the Modern World: A misdirected population leads to a "misdirected world". The best way to handle it is to "Educate the people" and change the "Attitude towards the right path" by promoting and accepting the value of Yoga, meditation and prayers (4).

Believe in nature & the green revolution, avoid global warming, maintain daily routine, which helps in curbing lifestyle related diseases.



1. The Bhagavata Purana (1.18.6), Vishnu Purana (5.38.8), and Brahma Purana (212.8), the day Krishna left the earth was the day that the Dvapara Yuga ended and the Kali Yuga began.

2. S.V Gupta. Units of Measurement: Past, Present and Future. International System of Units. Springer. p. 3

3. H.D. Dharm Chakravarty Swami Prakashanand Saraswati. Encyclopedia Of Authentic Hinduism The True History and the Religion of India, Hardbound, 2nd Edition, 2003 ,ISBN 0967382319

4. Lings, Martin. The Eleventh Hour: The Spiritual Crisis of the Modern World in the Light of Tradition and Prophecy. Cambridge, UK: Archetype, 2002

Competing interests: No competing interests

20 September 2017
Dr.Rajiv Kumar
Dept. of Pharmacology, Government Medical College & Hospital
Chandigarh 160030. India.
Re: Non-specific effects of measles, mumps, and rubella (MMR) vaccination in high income setting: population based cohort study in the Netherlands Fiona R M van der Klis, Elisabeth A M Sanders, Marianne A B van der Sande, Mirjam J Knol, et al. 358:doi 10.1136/bmj.j3862

Beneficial non-specific reduction in hospital admissions for respiratory infections following MMR and MenC vaccinations in the Netherlands

We appreciate that Tielemans et al.(1), using Dutch population data on vaccinations and hospital admission for infectious diseases, tested our findings of non-specific effects (NSEs) of the live attenuated measles-mumps-rubella (MMR) vaccine in Denmark(2). We found the transition from the third DTaP-IPV-Hib (DTP3) to MMR to be associated with a hazards ratio (HR) of 0.86 (95%CI=0.84-0.88). The Dutch study finds much stronger beneficial effect estimates for the transition from the fourth DTaP-IPV-Hib-PCV (DTP4) to MMR+MenC (HR for all admissions of 0.40 (0.38-0.41); for >1 day admissions 0.62 (0.57-0.67)), but also strong beneficial effect estimates for the previous transition from DTP3-to-DTP4 (HR all admissions 0.48 (0.46-0.51); >1 day 0.69 (0.63-0.76)). The authors conclude that healthy vaccinee bias at least partly explains the lower rates of admission after MMR and add that though NSEs cannot be excluded, NSEs cannot be distinguished from bias. The authors therefore emphasise the importance of caution in the interpretation of observational studies on the NSEs of vaccines.

There are several important contextual differences between the Danish and the Dutch studies. For instance, Denmark provides MMR at 15 months, whereas the Netherlands provides MMR+MenC vaccines at 14 months, and the NSEs of a live vaccine vs. co-administration of a live vaccine and a non-live vaccine have been shown to differ(3).

Most important in relation to healthy vaccinee bias is the difference in the organisation of vaccination. In the Netherlands, all children have pre-scheduled vaccination appointments, so 99.6% of all children had received MMR+MenC vaccine by 24 months of age. Judged by Figure 2(1), it was the sick children, who were delayed, since the admission rate increased in the unvaccinated children after 14 months. If almost all are vaccinated except sick children, this creates a strong healthy vaccinee bias, or maybe rather “unhealthy non-vaccinee bias”. In Denmark, parents have to schedule the vaccination appointments themselves; less than 90% had received MMR by 24 months; therefore the group of delayed children is more diverse and the admission rate did not increase in the unvaccinated children after 15 months(2).

It could be discussed whether it is meaningful to compare vaccinated versus unvaccinated children in settings like the Dutch, with severe healthy vaccinee bias. Tielemans et al. propose one way to control for healthy vaccinee bias: if we assume that the HR associated with the transition from DTP3–to-DTP4 is due to healthy vaccinee bias, then the relative difference in the HRs for DTP3-to-DTP4 and DTP4-to-MMR+MenC could be ascribed to the NSEs of MMR+MenC(1). The authors do not present the calculation, but if we use the HR for all admissions for the transition from DTP3-to-DTP4 as an indication of the “baseline” healthy vaccinee bias, then an adjusted HR for all admissions for the transition from DTP4-to-MMR+MenC can be estimated as 0.40/0.48=0.83 (95% CI=0.78-0.89). The correction of a HR for a vaccine by adjustment for the HR of another vaccine represents one way to deal with healthy vaccinee bias. It cannot be excluded that healthy vaccinee bias could be different in different age groups and the true estimate of the NSEs of MMR+MenC might well be larger or smaller than 17% (11-22%).

Are there other ways to control for healthy vaccinee biases? We have previously used triangulation methods to examine whether NSEs are the most logical explanation for all the data available. In the Danish study, we showed that DTP administered after MMR was associated with increased risk of admission, a tendency which cannot be explained by healthy vaccinee bias. Furthermore, both observational studies and RCTs(4) from low-income countries have suggested that measles vaccine is associated particularly with lower risk of respiratory infections. We therefore tested whether the reduction in admissions differed by disease category, or was similar for all categories as would be expected if healthy vaccinee bias were the main explanation. Corroborating the findings from low-income countries, the effect of MMR was smallest for gastrointestinal infection admissions (HR=0.93 (0.87-1.00)), being stronger for lower respiratory infections (HR=0.80 (0.76-0.84); p=0.001 for same effect as for gastrointestinal infections) and for upper respiratory infections (HR=0.86 (0.82-0.89); p=0.058).

In the Dutch study, MMR+MenC was likewise associated with the smallest reduction in gastrointestinal infection admissions (0.69 (0.61-0.78)) whereas the reductions were significantly stronger for lower respiratory infections (HR=0.57 (0.49-0.65); p<0.046) and for upper respiratory infections (HR=0.36 (0.34-0.37); p<0.001). In contrast, DTP4 was associated with the same reductions in gastrointestinal (HR=0.70 (0.61-0.79)), lower respiratory (HR=0.79 (0.67-0.82)) and upper respiratory infection admissions (HR=0.72 (0.62-0.82)) (p=0.299 for same effect; estimates for >1 day admissions, as no estimates for all admissions were reported)). Thus, relative to the reduction for gastrointestinal infections, MMR+MenC was associated with stronger reductions in admissions for lower respiratory infections (HR=0.80 (0.65-0.98)) and upper respiratory infections (HR=0.77 (0.64-0.93)), and the effect on lower respiratory infections and upper respiratory infections differed significantly between MMR+MenC vaccination and DTP4 vaccination.

Thus, there are two observations from this triangulation analysis, which cannot be explained by healthy vaccinee bias: First, the pattern of stronger reductions for respiratory infections than for gastrointestinal infections after MMR(+/-MenC) vaccinations seen in both the Netherlands and Denmark. Second, the effect of MMR(+MenC) and DTP3/4 on respiratory infections differed significantly in both the Netherlands and Denmark, with beneficial effect estimates of MMR(+MenC) but the opposite tendency for DTP4. Thus, in spite of severe healthy vaccinee bias, there was still important information supporting beneficial NSEs of MMR+MenC on respiratory infections in the Dutch study. Reassuringly, a beneficial effect of MMR on respiratory infections has also recently been reported by studies from USA(5) and Italy(6).

There is increasing epidemiological and immunological evidence that NSEs of vaccines are important(2-7). The number of RCTs testing NSEs is going to be limited for ethical and financial reasons. Hence, we rely largely on observational studies to assess NSEs. As shown here, using triangulation methods it is possible to distinguish NSEs from bias, even in settings with severe healthy vaccinee bias. Hence, we hope the Dutch call for caution is not interpreted as a call for caution against observational studies of the NSEs of vaccines.

Christine S Benn, Signe Sørup, Peter Aaby

Research Centre for Vitamins and Vaccines (CVIVA), Bandim Health Project, Statens Serum Institut, Artillerivej 5, 2300 Copenhagen S; OPEN, Department of Clinical Research, and Danish Institute for Advanced Study, University of Southern Denmark/Odense University Hospital, Denmark

1. Tielemans SMAJ, de Melker HE, Hahné SJM, Boef AGC, van der Klis FRM, Sanders EAM, van der Sande MAB, Knol MJ. Non-specific effects of measles, mumps, and rubella (MMR) vaccination in high income setting: population based cohort study in the Netherlands. BMJ 2017;358:j3862
2. Sørup S, Benn CS, Poulsen A, Krause TG, Aaby P, Ravn H. Live vaccine against measles, mumps, and rubella and the risk of hospital admissions for nontargeted infections. JAMA 2014;311:826-35
3. Higgins JPT, Soares-Weiser K, López-López JA, Kakourou A, Chaplin K, Christensen H, Martin NK, Sterne JAC, Reingold AL. Association of BCG, DTP, and measles containing vaccines with childhood mortality: systematic review. BMJ 2016;355:i5170
4. Martins CL, Benn CS, Andersen A, Balé C, Schaltz-Buchholzer F, Do VA, Rodrigues A, Aaby P, Ravn H, Whittle H, Garly ML. A randomized trial of a standard dose of Edmonston-Zagreb measles vaccine given at 4.5 months of age: effect on total hospital admissions. J Inf Dis 2014;209;1731-8
5. Bardenheier BH, McNeil MM, Wodi AP, McNicholl J, DeStefano F. Risk of nontargeted infectious disease hospitalizations among U.S. children following inactivated and live vaccines, 2005-2014. Clin Inf Dis 2017;epub
6. La Torre G, Saulle R, Unim B, Meggiolaro A, Barbato A, Mannocci A, Spadea A. The effectiveness of measles-mumps-rubella (MMR) vaccination in the prevention of pediatric hospitalizations for targeted and untargeted infections: a retrospective cohort study. Human Vaccines & Immunotherapeutics 2017; 13: 1879-83
7. Benn CS, Netea MG, Selin LK, Aaby P. A small jab - a big effect: nonspecific immunomodulation by vaccines. Trends Immunol. 2013 Sep;34(9):431-9.

Competing interests: No competing interests

20 September 2017
Christine S Benn
Center Leader, Professor
Signe Sorup, Peter Aaby
Research Centre for Vitamins and Vaccines (CVIVA), Bandim Health Project, Statens Serum Institut, Artillerivej 5, 2300 Copenhagen S; OPEN, Department of Clinical Research, and Danish Institute for Advanced Study, University of Southern Denmark/Odense University Hospital, Denmark
Re: Debating the future of mandatory vaccination Emma Cave. 358:doi 10.1136/bmj.j4100

Is it a surprise that no one has chosen to defend or enthuse about the safety of the current vaccination schedule, and the possibility of mandatory vaccination in the UK, as Anand has suggested they do, in the interests of an informed debate? (1)

There are two prominent industries in the USA and in the UK whose activities, risk profiles and potential compensation liabilities render them uninsurable on the international insurance market. They are the nuclear power generating industry and the vaccine industry, whose liabilities to litigation have been handed to government compensation schemes, funded by taxpayers.

This is reflected in a US Supreme Court judgement in 2011, which stated that vaccines are “ unavoidably unsafe products “. The judgement said that the industry should be exempted from strict liability for these products, as long as consumers are adequately warned about their risks. (2)

The Vaccine Damage Payment Scheme in the UK has played an uncertain role in compensating vaccine damage claimants, as Wendy Stephen recently explained. (3)

The vaccine industry is the most profitable division of pharma.

Inevitably so, with a business case that relies on an expanding variety of vaccines being produced, then introduced into national schedules, that will prove even more lucrative if those schedules become mandatory.

Corporate profits in the US and UK can be expected to increase, while the vaccine producer has no liability for any problems, injuries or deaths that may result from the use of their product. Very unusual.

The advertising, consultancy and lobbying budgets of pharma and it’s vaccine division have no global equal. (4)

GPs in the UK are paid for following NHS vaccination schedules for their patients, as are paediatricians in the USA, their payments coming from other sources. Practitioners who offer informed choices to patients about the timing and injection of vaccines, which deviate from national schedules, may lose money, and maybe invite criticism from colleagues, regulators and insurers. (5)

The concerns that many professionals have about the safety record of vaccines is very difficult to bring to the attention of the public, because of the influence that pharma has on the media. No owner nor editor is likely to want to antagonise one of their biggest advertising clients.

Many Rapid Responses in the BMJ in the past month, about vaccine safety, have raised areas of concern, providing numerous references and personal narratives, that should make any reasonable person wish to know more. (6)

So might the BMJ wish to know more, at a time when professional journals are becoming more alert to the perspectives of patients.

An up to date account of vaccine safety concerns, as well as careful historical assessment of the role of vaccination, since Jenner, should be mandatory reading for any professional whose work involves vaccination. (7)

Prepare to be surprised.

The Montgomery case, in the UK, has made it essential that patients are given a comprehensive account of the risks of any treatment, as Godlee pointed out. (8)

Just as the US Supreme Court had pointed out in 2011, respecting vaccine safety and liability (2)

Before mandatory vaccination in the UK is even discussed, perhaps we need to look closely at how much information patients and parents are being given, NOW, so that they can make informed decisions on vaccination.

I fear that Hinks’ first paragraph, anecdotal though it may be, points to the problem. (9)

Our profession may not only be neglecting to follow the Montgomery guidelines, with respect to vaccination.

Many of us may not have the knowledge that we should be sharing with patients, about vaccine safety.

Even more alarming, perhaps many of us do not appreciate the extent of our ignorance ?

5 Thomas and Margulis, The Vaccine Friendly Plan. Ballantine Books, 2016.
7 Humphries and Bystrianyk, Dissolving Illusions. 2015.
8 BMJ 2015;350:h1534

Competing interests: No competing interests

20 September 2017
Noel Thomas
retd/ part time GP
Bronygarn, Maesteg, Wales
Re: Paris Agreement’s ambition to limit global warming to 1.5°C still possible, analysis shows Ingrid Torjesen. 358:doi 10.1136/bmj.j4332

IMF report revealed that, every year, fossil fuel plants are subsidized with $5 trillion. [1][2]
If these funds were alternatively used in developing fusion nuclear reactors, like the TOKAMAK, global warming would have already been halted. [3]

Competing interests: No competing interests

20 September 2017
Stavros Saripanidis
Consultant in Obstetrics and Gynaecology
Re: The antibiotic course has had its day Cliff Gorton, John Paul, Tim E A Peto, Lucy Yardley, et al. 358:doi 10.1136/bmj.j3418

When I read this study which urges doctors to stop telling their patients to finish an entire course of antibiotics, the first thing I imagined was the impact this message would have on the consumer behavior of Tanzanians who are already grappling with antibiotic resistance.[1] The paper states, “patients should be encouraged to continue taking medication only until they feel better, to avoid the overuse of drugs.” and “Doctors must stop telling patients to finish an entire course of antibiotics because it is driving antimicrobial resistance.”

As a clinical pharmacist coming from a developing nation like Tanzania, where a layman lacks basic health knowledge – this study is very alarming. The impact such a message would have to the public would be detrimental. Experience has shown that whenever studies on such crucial health issues are published in renowned journals, the media here tends to hype the message—and quite often, the public may be left in confusion—more so, if the study is controversial.

My worry is that if this message makes big news here at home, it would cause poor medication adherence to not only antibiotics but other medications as well. Often times in Tanzania, antibiotics can be bought over the counter and many patients self-medicate. As a clinical pharmacist who strives hard to educate patients to complete their course of medications and advise doctors to not prescribe antibiotics irrationally, I find the recent study lacking evidence and needing more research before it can be incorporated into policy.

It is a known fact that poor adherence to antibiotics does lead to bacterial resistance. While I agree that antibiotics are misused, a global or national initiative against antibiotic misuse has been absent especially in the African continent. Currently in Tanzania, Ceftriaxone is widely misused and losing its effectiveness day by day.[2]

The recent study would make healthcare practitioners prescribe the medicine more often for a shorter duration adding to the burden of resistance. This would also cause a firestorm in the media, causing patients to demand short courses from health practitioners, making matters worse. Chloroquine, an antimalarial that was used to treat malaria in Tanzania is now ineffective.

One of the main concerns with irrational drug use is poor adherence and not completing the recommended dose. I believe the focus on curbing antimicrobial resistance should be to have a well-executed national and international plan which involves patient education, surveillance, new research as well as strict laws that stop livestock keepers using antibiotics as animal feed.

The scenario in England is quite different from Tanzania and Africa in general, a message such as the one published in the recent antibiotic study in the BMJ could cripple the health system in Africa as it is. In developed nations, patients can only get antibiotics through a prescription and often times after a culture test is conducted. In Africa, antibiotics can be bought from not only pharmacies but also basic medical stores without a prescription. While the Tanzanian government has tried to curb the problem by making culture sensitivity a compulsory for prescribing some common antibiotics in the National Health Insurance Fund, this is far from the solution.[3] The first step would be to strictly enforce and stop over the counter sale of antibiotics followed by the creation of a national antibiotic policy and guidelines.

It is well-known that antibiotic resistance is a future plague and as Dr. Margaret Chan, the then Director General of the WHO put it, “Resistance to antibiotics could bring an end to modern medicine as we know it.”[4] However, I do believe it is highly inappropriate at this time, to state that patients should be encouraged to continue taking medications only until they feel better. More research to prove this is needed before changes in policy can take place.


Competing interests: No competing interests

20 September 2017
Sajjad S Fazel
Clinical Pharmacist & Public Health Advocate
Schulich School of Medicine & Dentistry, University of Western Ontario
Re: Bernie Sanders’ single payer bill gains momentum among Democrats Owen Dyer. 358:doi 10.1136/bmj.j4310

In order that they don't mess up their proposed single payer health care system as we have ours, The NHS, I suggest they read 'The Tyranny of a System - The NHS'

Competing interests: No competing interests

20 September 2017
Rod A Storring
Consultant Physician
Spire Roding Hospital
Re: Chronic vertigo: treat with exercise, not drugs Vincent A van Vugt, Henriëtte E van der Horst, Rupert A Payne, Otto R Maarsingh. 358:doi 10.1136/bmj.j3727

We congratulate Van Vugt et al. for giving necessary attention to the common problem of chronic vertigo, unsteadiness, and dizziness. We wholeheartedly agree with their recommendation to limit the use of vestibular suppressants and move patients quickly into a rehabilitation plan. However, the clinical management such patients is incomplete without a better understanding of the nature of their condition. The Barany Society (the international neuro-otology research organization) and the World Health Organization recently defined the syndrome of persistent postural-perceptual dizziness (PPPD) based on 30 years of research into the interactions of physical and psychological factors that trigger and sustain chronic vestibular symptoms. We find it a useful description of the often complex clinical reality of many patients who seek advice in secondary care. Familiarity with PPPD and its differential diagnosis offers greater clarity in evaluating and managing patients with chronic vertigo and dizziness. We hope that recognition of PPPD will allow medical professionals and patients a better understanding of this common problem; one where relevant biopsychosocial predisposing, precipitating and perpetuating factors are recognised and incorporated into successful interventions.

(1) World Health Organization, International Classification of Diseases, 11th edition beta draft (ICD-11 beta), definition of persistent postural-perceptual dizziness,
(2) Dieterich M, Staab JP. Functional dizziness: from phobic postural vertigo and chronic subjective dizziness to persistent postural-perceptual dizziness. Curr Opin Neurol. 2017 Feb;30(1):107-113.

Competing interests: No competing interests

20 September 2017
Dr Jan A Coebergh
consultant neurologist
Professor Jeffrey Staab, Mayo Clinic, USA
Ashford St Peters hospital; Honorary Consultant Neurologist St George's Hospitals
Re: A smoke-free generation? John Britton. 358:doi 10.1136/bmj.j3944

Tobacco is an addictive depressant that tricks and traps us by creating the fleeting euphoria of relaxation and aeration, but the sustained sickness of desperation and suffocation. The euphoria of relaxation and aeration, and the sickness of desperation and suffocation, are polar opposites that reinforce each other: the euphoria blinds us to the sickness, and the sickness makes us crave the euphoria. Perversely but predictably, tobacco creates, aggravates, and perpetuates the very sickness of desperation and suffocation that it falsely seems to cure, thus placing all tobacco products in a very bad light.

Competing interests: No competing interests

19 September 2017
Hugh Mann
Re: WHO report says countries should do more to prevent suicides Gareth Iacobucci. 349:doi 10.1136/bmj.g5461

Clinical research evidence shows that religious/spiritual awareness-practice drastically reduces symptoms of depression and suicides.
Countries should include religious/spiritual interventions in mainstream practice.

Competing interests: No competing interests

19 September 2017
Stavros Saripanidis
Consultant in Obstetrics and Gynecology
Re: Working when exhausted is unacceptable Paul D McGovern. 358:doi 10.1136/bmj.j4191

As someone who trained in the bad old days I for one haven't forgotten the miserable long shifts that we endured in the name of service.

The reality is that we wasted the best years of our lives propping up the NHS which (as now) was under doctored compounded in those days by derisory rates of pay that say some juniors being paid the lowest hourly rate of pay in the hospital. No wonder when UMTs were paid at rates that wouldn't get a domestic.

Falling asleep standing up and in the bath are delights I would rather not repeat.

Now some fools wish to bring that back in the name of training and continuity. No doubt management hope it will help to cover the gaps.

Training is more about quality than quantity but in an era training is measured by counting ticks in boxes there will those who don't understand that repetitive mundane tasks that juniors still end up doing like chasing bloods, phlebotomy and giving drugs because there aren't enough trained nurses is not not training.

For pity's sake we are losing Drs from the profession at an alarming rate already and even more to other countries. Poor pay, poor training, overwork are not enough: now some want to add sleep deprivation into the mix!

Competing interests: No competing interests

19 September 2017
Andrew P Moltu