| · Influenza pandemic
· Preregistration training
· COX-2s
· CAM
· Controlled drugs
· Medicines use reviews
· Pharmacy practice
Letters to the Editor
|
Influenza pandemic
Might oseltamivir be a mixed blessing?
From Dr H. Pickles and Mrs V. Tailor, MRPharmS
The antiviral oseltamivir (Tamiflu) is a mainstream of UK government
policy for dealing with pandemic influenza.1 As flu pandemic
co-ordinators struggle to make viable local plans for its storage and
distribution, the mixed blessing it creates becomes more apparent.
First, will it work at an individual level? The National Institute for
Health and Clinical Excellence had doubts in relation to regular flu,2 and it has yet to be tested for the pandemic strain. The adverse effects
may be significant and resistance has been reported,3 and the more widespread
the use of oseltamivir, the more likely this becomes. The formula for
children is not yet ready and is untested. Conditions may have to be
optimum for it to have any effect. Even so, the individual benefit may
not be great nor can it be relied upon. Deaths may still occur after
treatment with oseltamivir.3
Secondly, there are all the logistic issues of ensuring those most in
need access it when those optimum conditions can be met. The appropriate
symptoms for less than 48 hours with a fever of at least 38C are said
to be required, but how those requirements would be validated at a dispensing
stage is unclear. In any event, for those ill at home, it makes sense
for a third party to collect the medicines. Encouraging the infected
to attend pharmacies or emergency treatment centres, and so spread disease
to the pharmacist and to other customers, needs to be avoided.
None of this would matter if there were plenty to go round and resistance
was not an issue. But neither is the case. Access will have to be limited.
The DoH has said it should be available for all-comers, so being registered
with the NHS cannot be a criterion for access. Will it require use of
the drug to be directly observed to ensure supplies are not for stockpiling
or selling on? Not all oseltamivir offered in bars or on e-Bay will be
counterfeit.
However careful the central policy and local actions, there will be perceived
to be insufficient supplies. Hence there is the need for secure storage
and plans for dealing with those angry at being denied the drug. In a
pandemic there will be plenty of media images of the death toll world-wide,
and if oseltamivir is “sold” as life-saving many will be
desperate to get supplies.
Health care workers and other essential workers may quite reasonably
assume stocks will be secure for them if needed, but many others may
feel the same and use their muscle to ensure they have privileged status,
too. Indeed, the business sector, on being informed of the threat of
pandemic flu, will want to know how their workers can be designated as
key and hence be privileged recipients of limited supplies.
This will become divisive, and lead to difficult rationing decisions.
Prophylaxis of immediate contacts in the early stages in an attempt to
stamp out the incipient pandemic will be rapidly abandoned when the full
pandemic is on us. However, those with access to supplies may feel differently
if occupationally exposed, and put what they think are their short-term
personal interests first. Most nations do not have the stockpiles we
have in the UK, risking others coming here for our supplies, infecting
others en route. For good reasons, prisoners and their warders may need
some priority, but this will not go down well with the public.
Presumably we can, and will, work through all the above issues. If infectivity
is dampened down and complications reduced, at one level oseltamivir
will have worked at a population as well as an individual level.
But at what price? The real outcome we are striving for is a cohesive
society at peace as it tries to rebuild itself once the pandemic is over.
The current emphasis on vaccines and antivirals may be necessary to justify
the current government spend, but channels thinking into a medical model.
It would be far better to stress all the positive things4 which can be
done by those who will be without antivirals, either because they are
ineligible or because the drugs are rationed or turn out to be ineffective.
Of these, increasing social distance and handwashing are important, but
wearing face masks is of little value. We must avoid recriminations over
who did and did not receive oseltamivir becoming a running sore in the
post-pandemic period.
A new consensus is needed, dampening down expectations of antivirals,
and raising the profile of all the other measures available and seeing
beyond the hype. Even if the worse fears materialise, the vast majority
will emerge from the pandemic with full physical health. Life will and
must go on after the pandemic.
Hilary Pickles
Director of Public Health
Vasundra Tailor
Head of Medicines Management
Hillingdon Primary Care Trust
References
1. UK operational framework for stockpiling, distributing and using
antiviral medicines in the event of pandemic influenza. London: Department
of
Health; 2005.
2. NICE Technology Appraisal no 58. Guidance on the use of zanamivir,
oseltamivir and amantidine for the treatment of influenza. London: NICE;
2003.
3. De Jong MD, Thanh TT, Khanh TH et al. Oseltamivir resistance during
treatment of influenza (H5N1) infection. New England Journal of Medicine
2005;353:2667–72.
4. World Health Organization Writing Group. Non-pharmaceutical interventions
for pandemic influenza, national and community measures. Emerging Infectious
Diseases 2006;12:88–94. |
The
Pharmaceutical Journal