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NEWS: Adrian O’Dowd UK swine flu cases near 3000, as GP leader says use of Tamiflu may need to be rethought BMJ 2009; 338: b2565 [Full text]

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Policy on the use of antiviral drugs needs to be revised

Peter M English, Kevin Carroll, Azeem Majeed, Torbjorn Sundkvist, Sally Millership, and Sharon Chambers   (26 June 2009)

Policy on the use of antiviral drugs needs to be revised 26 June 2009
Peter M English, Business Secretary Public Health Medicine Environment Group, c/o Dorset House, 297 Kingston Road, Leatherhead, KT22 7PL, Kevin Carroll, Azeem Majeed, Torbjorn Sundkvist, Sally Millership, and Sharon Chambers Send response to journal: Re: Policy on the use of antiviral drugs needs to be revised	Current swine flu policy in London recommends antiviral agents for patients who have had a temperature > 38 C in the past 7 days and who have two or more symptoms of flu-like illness.[1] Even during the summer months, when rates of flu-like illness are relatively low, active application of this policy will result in a large number of people being prescribed antiviral agents. If people with mild illness are to be treated with antiviral agents, we need a clear evidence-base to justify this policy to ensure that it is effective in clinical, public health and economic terms; and to ensure that we are not unnecessarily exposing large numbers of people to drug treatment, with the risk of associated side-effects.[2] We should consider acting as we do during seasonal flu, similar to the current Australian policy and for similar reasons.[3-6, 7] We are concerned that the public is being given the message that swine flu has a serious risk of complications. But there is no evidence that treating people more than 48 hours after the onset of illness provides significant clinical benefits. In practice, delays in reporting, testing and organising treatment for so many people have meant that very few symptomatic cases have had treatment soon enough to make any significant difference to the course of their illness. If antivirals cannot be given to cases in time to reduce their illness, then the only possible benefit from antivirals is a possible reduction in viral shedding, and therefore a possible reduction in the risk of infection to others. While neuraminidase inhibitors (NIs) may reduce viral shedding,[8] we are unaware of any evidence that their use adds significantly to advice regarding self-isolation and hygiene measures. If there is any additional evidence of benefit from this treatment, policy-makers have failed to publicise it, and the rationale for treatment. By using antiviral drugs so liberally - for what is still currently a mild form of influenza - we risk generating resistance to these drugs so that when a more virulent form of influenza presents, the drugs may no longer be effective. It is our concern therefore that the current policy on the use of antiviral drugs is probably doing more harm than good, even without taking into account the enormous resource implications, the important work left undone by GPs and other NHS staff having to focus their efforts on swine flu, and the loss of staff good-will. We question the need to continue the use of antivirals for people who are not at high risk of complications. We hope that the BMJ and other scientific journals can discuss these issues in a rational manner to ensure that scientific considerations, rather than the imperative of being seen to be doing something, drives UK public health policy. Disclaimer We have written this letter in our personal capacity. The views represented in this letter do not necessarily represent the views of our employers, or any organisation to which we may be affiliated. References 1. HPA and NHS London Algorithm. http://www.lmc.org.uk/uploads/files/news/2009/londonswinefluhpaalgorithmjun09.pdf 2. Rouse A, Chambers J, Gosling RD. Rapid responses to Adrian O'Dowd, UK scientific adviser criticises UK planning for flu pandemic, BMJ 2009; 338: b2316. 2009; Updated 23 June 2009; Accessed: 2009 (23 June 2009): Rapid Responses ( http://www.bmj.com/cgi/eletters/338/jun09_1/b2316#215495http://www.bmj.com/cgi/eletters/338/jun09_1/b2316#215495). 3. National Institute for Health and Clinical Excellence. Amantadine, oseltamivir and zanamivir for the treatment of influenza (review of NICE technology appraisal guidance 58). London: National Institute for Health and Clinical Excellence, 2009 (February 2009); 1-2 ( http://guidance.nice.org.uk/TA168/QuickRefGuide/pdf/English). 4. National Institute for Health and Clinical Excellence. Oseltamivir, amantadine and zanamivir for the prophylaxis of influenza (including a review of NICE technology appraisal guidance 67). London: National Institute for Health and Clinical Excellence, 2009 (February 2009); 1-2 ( http://guidance.nice.org.uk/TA158/QuickRefGuide/pdf/English). 5. Roxon N. New Pandemic Phase PROTECT. Canberra: Department of Health and Ageing (Australia), 2009 (17 June 2009); ( http://www.health.gov.au/internet/ministers/publishing.nsf/Content/mr-yr09-nr-nr082.htm). 6. Department of Health and Ageing. National incident Room H1N1 Influenza 09 PROTECT phase - Questions and Answers. Canberra: Department of Health and Ageing (Australia), 2009 (17 June 2009). 7. Grayson ML, Johnson PDR. Australia's influenza containment plan and the swine flu epidemic in Victoria. Australian Medical Journal (eMJA - Rapid Online Publication), 2009( http://www.mja.com.au/public/issues/191_03_030809/gra10697_fm.html ). 8 Jefferson TO, Demicheli V, Di Pietrantonj C, Jones M, Rivetti D. Neuraminidase inhibitors for preventing and treating influenza in healthy adults. Cochrane database of systematic reviews (Online) 2006;3(3):CD001265 (http://www.cochrane.org/news/articles/CD001265_standard.pdf). Competing interests: None declared