It has emerged over the weekend that the UK government ignored the advice of a key panel of scientific advisors in the formulation of its pandemic response. The panel advised against the mass prescription of antivirals (Tamiflu) because of the fear that this would accelerate resistance of the virus (see also this previous post in the pandemic ethics series). An expert in influenza, Hugh Pennington, has even called for the national flu hotline to be shut down. It appears that the government may have been influenced in its pandemic response by political sensitivities.
Part of the problem is that this pandemic influenza strain appears to be relatively mild. There has been speculation about, and preparation for, a new influenza pandemic for some years. The stockpiling of anti-virals and the development of distribution systems that would reduce the burden on the health service (for example the flu hotline) were designed to deal with a pandemic with high mortality. But, although this new strain of influenza has caused serious illness and death in a small number of individuals, thankfully it is nowhere near as bad as feared.
The Committee on Ethical Aspects of Pandemic Influenza recommended that anti-virals be given only to those at higher risk, for example pregnant women or those with pre-existing illnesses. But this approach was rejected, at least in part because of a feeling that the public would not accept rationing of antivirals when there was an existing large stockpile. In the first fortnight of the national flu hotline more than 500,000 courses of anti-virals were prescribed.
The hotline has some definite advantages. It takes the pressure off GPs and emergency departments as well as streamlining access to antivirals for those who genuinely have influenza and would benefit from treatment. It potentially serves to reduce spread of the virus by preventing patients from attending clinics and hospitals. But there are also risks. As I discovered myself this morning, (I have a mild flu-like illness at present), the criteria for ‘diagnosis’ of influenza are so broad that they include almost any patient with a febrile illness. There have been a number of stories in the media in the last week of patients with other serious illnesses (see here, here, or here) who have received a telephone diagnosis of influenza and as a consequence have delayed presentation to hospital. There have also been large numbers of patients developing (mostly mild) complications from the anti-virals. The biggest concern is that using up the stockpile of antivirals on patients who may or may not have influenza, and who have a very low chance of benefit, risks the drugs not being available, or not being effective come winter.
There is, of course, a balance to be achieved in public health policy between optimal community benefit, and public acceptability. But short term political expediency may come at long term political cost. The current pandemic response needs to be reconsidered.
Experts warned dispersal of Tamiflu would do more harm than good Guardian 16/8/9
Ministers ignored advice on mass issue of Tamiflu Telegraph 17/8/9
Do you think the website might be even more worrying than the hotline? I would have thought it was easier to lie to that than a real person on the phone, and that many people would deliberately tick boxes to get the drug in case they need it in the future.
Do you think we could do with a government ad-campaign about the risks of drugs making viruses more resistant? It seems at the moment even if people are aware that that might happen, they are more worried about their family recovering now, than some unspecified possibly worse virus in the future which might not affect them at all. Perhaps pointing out its being a real danger to everyone might help avoid people being over-eager to take drugs on the off chance they have swine-flu?
There are two factors that contribute to the current ‘liberal’ approach to antiviral prescription. The first is that both the telephone hotline and the internet service recommend a course of tamiflu for patients with a wide range of symptoms and at low risk of developing complications. There may be some people who are attempting to get hold of some Tamiflu while they can to keep for later, but I suspect that most people who are prescribed the drug are unwell with something. It is just that they may or may not have influenza, and they may or may not get any benefit from Tamiflu.
The second problem that contributes to the widespread overuse of antivirals is the public misunderstanding about how effective these drugs are, and how serious influenza is. Many people are prompted to take the drugs because they are afraid of serious complications of the illness, and because they have been led to believe that the antivirals are (in the words of Professor Pennington) ‘wonderdrugs’. Whereas in fact the bast evidence is that, if taken early in the illness oseltamivir (tamiflu) reduces the duration of flu-like symptoms by 1 day. There is not good evidence that it reduces your chance of getting seriously ill from influenza, though it is hoped that it might.
So, if the government were to change tack and adopt a more focussed strategy of antiviral prescription your suggestion of an education campaign about antivirals and about the virus would be important.
One interesting point that occurred to me after I had written the above post is about strategies for avoiding risks and political liability. The department of Health’s response to the suggestion that expert advice (to limit antiviral prescription) had been ignored was to say
“There is still doubt about how swine flu affects people – a safety-first approach is the best approach. This means offering antivirals when required”
But since the advice given to the government was that the chosen strategy was potentially the riskier strategy – given what we know, it seems that decision-making was influenced by a desire to avoid one type of risk. Politicians are particularly keen to demonstrate that they are *doing something* in response to a problem. There may be an asymmetry between acts and omissions in political liability. An omission (in the face of a possible risk) may be judged more harshly that a well-meaning act?
cheers
Dom
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