Observations BMJ Open Data Campaign

Open letter to Roche about oseltamivir trial data

BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e7305 (Published 29 October 2012) Cite this as: BMJ 2012;345:e7305

Re: Open letter to Roche about oseltamivir trial data

We have good reason to share the emerging concerns about the financial and public health cost of Governments maintaining their Tamiflu orthodoxy during the H1N1 outbreak in the face of evidence demonstrating the indefensibility of such a position. The insistence on managing ‘England as a single epidemiological unit’ [1], and maintaining the ‘containment’ phase beyond any rationality led directly to perverse, expensive and ultimately ineffectual interventions.

The mass chemotherapy response of the UK Government to the H1N1 outbreak was entirely without precedent [2] and the mechanics of its imposition contrary to the evidence. Sandwell, a modest urban municipality, used the best evidence available to ensure that Tamiflu was only administered where clinically justified including in a clinical risk group, contact with a case, and able to start treatment within 48 hours [3]. This was an enormous logistical enterprise but staff were motivated by ‘doing the right thing’ in the right way. This evidence based response was swept away without consultation and replaced by the centrally imposed, misguided and opportunistic largesse of the national on line Tamiflu free for all; a decision with taken with no respectable evidence of effectiveness.

Many of us in PCTs considered our role to have been transformed from front line public health to that of an NHS delivery system for the pharmaceutical industry. Anti-viral collection centres doubled as publicly funded venues for protracted ‘pox parties’ enticing hundreds of cases and contacts to share a relatively confined space. There is growing evidence that flu can be spread through sub-clinical cases, creating the potential for any assembly of the public to spread the infection [4, 5]. This should be the major control consideration for planning to prevent pandemic spread in future. Our views (and we understand we were not alone in raising these concerns) expressed at the time to the Department of Health were ineffectual.

It is one thing to make compromises between public and political expectations when the evidence is uncertain It is quite another to collude with a disregard for the evidence despite legitimate and informed objections.

[1] Chambers J, Barker K, Rouse A. Reflections on the UK’s approach to the 2009 swine flu pandemic: Conflicts between national government and the local management of the public health response. Health Place 2012; (18): 737–745.
[2] Ellis C, McEwan R. Editorial on use of antivirals. BMJ 2009; 339: 2639.
[3] NHS National Institute for Health and Clinical Excellence Technology appraisals TA158, September 2008. http://www.nice.org.uk/guidance/TA158 last accessed 17th December 2012.
[4] Centers for Disease control. Additional Information about Vaccination of Specific Populations. Influenza Prevention and Control Recommendations. Published for the 2010-11 Influenza Season; Adapted for the 2012-13 Influenza Season http://www.cdc.gov/flu/professionals/acip/specificpopulations.htm last accessed 17th December 2012.
[5] Chao D-Y, Cheng K-F, Li T-C, Wu T-N, Chen C-Y, et al. Serological Evidence of Subclinical Transmission of the 2009 Pandemic H1N1 Influenza Virus Outside of Mexico. PLoS ONE 2012; 6(1): e14555. doi:10.1371/journal.pone.0014555

Competing interests: No competing interests

18 December 2012
Patrick J Saunders
Consultant in Public Health
John Middleton, Anna Pronyszyn, Mary Tooley, Michele Lawrence, Claire Parker
Sandwell PCT
Kingston House, High St, West Bromwich, B70 9LD