"Instead of giving us orders, they should sign contracts with us and pay us!" argues Gyula Keszthelyi, general practitioner, who thinks nobody can force doctors to vaccinate people for free. In his view, GPs should receive just as much money for giving someone a flu vaccine as the Medical Officer's Service asks for a non-obligatory injection from those travelling abroad, which is HUF 4500. Instead, the state is planning to pay HUF 200 after each injection and doctors would only be able to ask for HUF 1930 from patients not entitled to free protection (because they are neither pregnant, nor infants, and do not have a heart condition). It seems that the ministry could not have done a better job of turning doctors against the vaccination campaign even if this had been its original aim. While vaccines are delivered in the hundred thousands, nobody knows who and when will pay the fee of HUF 200 to doctors after each vaccine they administer.

The power of 'web doctors'

50 years ago, Mr Keszthelyi would just have been a village doctor, quietly grumbling under his breath and complaining to the elderly ladies among his patients. Today, - thanks to giulio.freeblog.hu, the debating website he set up - his influence on people is comparable to that of the Hungarian Pandemic Commission. Tens of thousands of laymen read his fuming remarks on the site. In addition, he is also a regular visitor adding comments to several internet forums visited by other members of the profession, where the contradictory actions of the government are critically analysed to the tiniest detail. Keszthelyi found himself in the middle of a whole movement, when Ferenc Falus, the National Medical Officer threatened him with a fine of HUF 1 million and the withdrawal of his licence, because he refused to administer the state-provided flu vaccines for free. According to doctors, it is unacceptable that the government places the burden of preparation on them, while it keeps emphasising that H1N1 is a dangerous virus with the majority of the population being vulnerable to it.  Therefore the number of those infected and those treated in hospital will be higher than average, just like the number of fatalities. Practically, mass vaccinations have been announced, but with assembly line methods. The government has ordered 6 million vaccines (4 million to be given for free and 2 million available in pharmacies); this means that in a surgery with 2500 people, 1500 patients would need to be vaccinated in two months. Twenty five people each day of the week.

Although negotiations were still under way during the summer on the delivery of vaccines by refrigerator vans, eventually a "cheapskate" solution was agreed: GPs will have to collect vaccines from the Medical Officer's Service. Were anyone to shoot a documentary entitled "Virus" about the preparations for the epidemic, he would not find the slightest trace of modern technology being used. The film would show a doctor taking his cooler bag, - otherwise used at the beach - dropping two ice packs into it and leaving for a Medical Officer's Service station. If a shopkeeper did the same with a tray of yoghurt pots, he would receive the highest fine possible for having breached food safety regulations - but the vaccines that are to be stored between 2 and 8 degrees Celsius are transported in this way by doctors each day. Medical professionals also criticise the manufacturer, Omninvest Ltd for having left out the so-called heat register from the packages to save money. This would automatically log the temperatures the vaccines were stored at at different times.

Thermometer in the cooler bag

"How should I know whether the vaccine is still good by the time it reaches me?" asks Gyula Keszthelyi, reminding us that two weeks ago temperatures during the day in the country were around 27 degrees Celsius. And something that should be a bad joke and not reality: none of the twenty ampoules in each box carries either the use-by date, or the date of manufacture. The doctor or his assistant has to write this onto the labels, taking the ampoules one by one. According to doctors, the fact that the accompanying instructions allow the vaccine to be administered to children from the age of 6 months is also unacceptable. They are afraid of possible court cases as, up until last week, the vaccine could not be given to patients under the age of 18, because there was no valid marketing licence for its use on children when the deliveries started (for those under 3 years, no such licence existed as Heti Válasz went to press). In the opinion of the National Institute of Pharmacy, legal requirements are complied with.

In the meantime, public health officials are acting as if they were stakeholders in Omninvest Ltd, the company whose proprietorship is unclear. Several members of the Pandemic Commission advised the National Medical Officer in September to carefully consider the question of vaccinating expectant mothers, even though they are at the highest risk from the disease. It‘s primarily family members who should be vaccinated, and, should they become infected, pregnant women should be given antiviral medication. Despite all this, Ferenc Falus, the National Medical Officer decided to announce in public that expectant mothers should be the first to receive the vaccine. It was later added that the final decision is to be made by general practitioners themselves, who think the government have just shifted responsibility to them and they will be held to account in any future compensation cases.

GPs were quick to react: signs have appeared in hundreds of surgeries warning people that the responsibility for vaccination lies with them and they are required to confirm in writing that they will not demand any compensation for damages. Although such practices were criticised by the Ethics Council, GPs still feel there is no other way to protect themselves from the orders of public health authorities. A war of public statements broke out on Monday. Despite the fact that several professional colleges declared the Omninvest vaccine to pose no dangers for pregnant women, the infectology body which deals with contagious diseases, still maintained its earlier opinion. They published an announcement stating that because the Hungarian vaccine has stronger side effects, foreign vaccines are recommended for expectant mothers. The only problem is that these are not available in Hungary.

The complications of confusion

However, the syringe is in the hands of GPs - the ministry seems to be gradually realising that resistance on the part of practitioners could mean the failure of the vaccination campaign as a whole. Zsuzsanna Sebő, a general practitioner, said just a few weeks ago that since there was no experience regarding vaccinating children under 3, she would not administer the injection to her own child and that she did not recommend it to others, either. Thousands of doctors and parents quote her on the internet, her statement can be seen on noticeboards in many places. András Szalka, a member of the professional college backed Sebő's opinion, saying in an interview to TV2 that children under 5 should not be vaccinated.

Medical professionals involved in the information exchange on the internet also think it is a "catastrophe" for the profession that in theory, the two vaccines - one against seasonal flu, the other against the new flu - should be given on the same occasion, one in one arm, the other in the other. They are not alone in questioning this method: the 'two vaccines into two arms' solution is not recommended in the UK either; warning was given that it might be too demanding on the body.

The fact that there is not much confidence between the minister and the Medical Officer (the Socialist Party did not allow Falus to be removed from his post) does have an impact on official communication. Relations are not harmonious with the members of the Pandemic Commission, either. Statistics are not available as yet, but the confusion could lead to a mass of vaccines left in warehouses and no one has any idea what will happen to such vaccines, as the contract concluded with Omninvest is confidential.

The most serious problem is that in the heat of the debate, there is less and less attention left for the increasing number of patients. Although the disease has not developed into a pandemic yet, there are already four fatalities according to official records. (Germany has a hundred times more infected with half the number of fatalities.) Eventually, as of the second half of September, Hungarian authorities also started to register the number of those admitted to hospital with the disease (14) and those treated in intensive care units (5). The proportion of the latter is unusually high even in an international comparison and is a warning sign that patients in Hungary only receive hospital treatment if their condition is quite serious.

The Problem

To prevent a pandemic, 50% of the population needs to be vaccinated. This means that a GP should vaccinate 25-30 people every day, which causes long queues.

GPs are afraid of being made to take responsibility for compensation for the possible side-effects caused by vaccines.

The ownership structure of Omninvest Ltd is not known, which leads to a further loss of confidence in the vaccine.

The Solution

Vaccination centres should be nominated where those who want to be vaccinated could be given the injection fast. Access to vaccines provided after payment should be made simpler, so that people would not have to go to the pharmacies as well.

The state should assume the task of holding Omninvest Ltd responsible for its product.

The name of stakeholders in the company should be made public, just like the contract it concluded with the Hungarian state, which was classified as secret for a period of ten years.

How do others do it?

» Quick to act: In the UK, the US and Germany, they are starting to deliver the vaccines this week. The vaccine is also already available in Romania, but vaccinations will only start within a few weeks' time.

» Voluntary vaccination: People are free to decide whether they want to be vaccinated, except for the US, where it is obligatory for healthcare workers to be injected - they promptly demonstrated against this.

» Free of charge: The vaccine is free of charge for the whole population in the US and the UK, they are not required to pay for the injection to be administered, either. Western countries ordered vaccines from several different manufacturers; everyone can decide which one they choose. In Hungary, vaccines are being delivered to pharmacies this week.

» Safety: In Germany, a "milder" vaccine is produced for children and expectant mothers. Fever is one of the possible side effects of the 'normal' vaccine. The intention was to avoid it with the use of the milder version. The fact that politicians and soldiers are also given this "milder" version has caused a scandal.