First do not harm

First do no harm

Fiona Godlee, editor, BMJ

fgodlee@bmj.com

Most countries in the world have heeded the World Health Organization’s call to include hepatitis B vaccine in childhood immunisation programmes. But six countries in Northern Europe, including the United Kingdom, have not. Why are they holding out? Hepatitis B infects two billion people worldwide, causing hundreds of millions of chronic infections and early deaths from liver disease. About 14 million people in Europe are chronically infected.
Such high numbers help Pierre Van Damme and colleagues make a good case for the remaining six European countries to fall into line (doi:10.1136/bmj.f4057). The alternative approaches—targeting people at high risk and preventing perinatal transmission—are hard to implement, they say. But Tuija Leino and colleagues argue persuasively against universal vaccination in these non-endemic countries. They explain that the main aim of hepatitis B prevention is to stop people becoming carriers. Most infections in low endemicity countries occur in young adults, among whom rates of lifelong virus carriage are less than 5%. Immigration is the main source of new carriers in these countries, and childhood vaccination would have minimal impact on the prevalence of carriers, they say. Better to focus efforts on effective programmes for antenatal hepatitis B screening. Last week’s editorial on hepatitis B in China summarised the current best options for interrupting mother to child transmission in infected women (BMJ 2013;347:f4503).
The tendency to favour universal prevention programmes is questioned elsewhere in the journal this week. The UK government recently announced that all adults aged 40-75 will be offered regular free health checks. On the face of it, this sounds like a good and generous plan. But Felicity Goodyear-Smith asks: "do benefits outweigh harms, do false negatives lead to inappropriate reassurance, or do false positives lead to over-investigation and over-intervention?" (doi:10.1136/bmj.f4788). Screening always comes with social and financial costs, she says. With primary care services already heavily stretched, this latest government initiative doesn’t sound like good medicine or good value for money.
Nor does the new catch all definition of chronic kidney disease. Continuing our series on overdiagnosis, Ray Moynihan and colleagues explain that the large numbers of people now labelled as having chronic kidney disease (14% of all adults), combined with the low rate of total kidney failure, suggests that many of those diagnosed will never develop symptoms (doi:10.1136/bmj.f4298). The authors recommend clinical scepticism about the current definition and call for caution in labelling patients, especially older people.
What then of plain packaging for cigarettes? Here’s an intervention that seems poised to improve public health. As Crawford Moodie and colleagues recount, Australia’s experiment continues apace and the growing body of research is consistent in finding that plain packaging would reduce the appeal of tobacco products, particularly among children (doi:10.1136/bmj.f4786). Research also suggests that it would make health warnings more effective and make it harder for manufacturers to mislead smokers about the risks. So what’s stopping other governments from following Australia’s lead? Not an absence of good evidence but a lack of political will.
Cite this as: BMJ 2013;347:f4843