Does this recent DTB editorial encapsulate some of the concerns expressed on
the discussion group?
Drug and Therapeutics Bulletin 2009;47:97; doi:10.1136/dtb.2009.08.0034
EDITORIAL: Tamiflu - the wrong message?
Widespread use of {blacktriangledown}oseltamivir (Tamiflu) has been a key
strategy in tackling the H1N1 'swine flu' pandemic in the UK. Is the
increasing disquiet about this policy justified?
In clinical trials on seasonal influenza, neuraminidase inhibitors
(oseltamivir and zanamivir) have reduced transmission of influenza A but
provided only modest symptomatic improvement. Oseltamivir's use in the
current H1N1 pandemic has had various objectives: to limit transmission; to
reduce fatal complications; and to limit the socioeconomic burden by
shortening illness and increasing public confidence that treatment is
available. However, since this is oseltamivir's first use in a pandemic,
none of these is underpinned by strong evidence, despite allusions to the
contrary from health officials and politicians. This weakness is illustrated
by the failure to prevent widespread transmission. The limited evidence
base, and the low mortality rates so far in the pandemic, also underlie the
scepticism about widespread use of oseltamivir. Defenders of the policy
might argue that urgent situations sometimes require action despite
incomplete evidence. But in such cases, transparent risk assessment is
crucial, as is honest communication to the public. So, it is regrettable
that obvious potential problems from widespread use of oseltamivir were not
presented openly from the outset. These include encouraging viral
resistance; unwanted effects of oseltamivir; costs of the drug, and the
added costs and disruption to the NHS in ensuring ready access to
oseltamivir; black market resale of the drug; and depleting antiviral stocks
should H1N1 flu become more virulent as the pandemic 'matures'. Also, the
undue emphasis on oseltamivir could well have undermined the public
perception of the importance of standard hygiene and other control measures,
and potentially fostered the dangerous practice of assuming any febrile
illness is flu requiring oseltamivir, thereby delaying diagnosis of other
infectious diseases.
The risk benefit analysis of the policy on oseltamivir deserved more open
and balanced public discussion. On this measure, at least, the policy has
failed and should be reviewed urgently.
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Martin Duerden
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