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Should Tamiflu be offered to all patients with swine flu symptoms?

Antivirals are important for easing the peak of illness and, as we can't identify who most needs them, a blanket approach is the only option, says Professor David Price. But Dr Helena Newman argues that the policy of blanket antiviral use is costing the NHS a fortune, inappropriately cosseting patients and risks fuelling drug resistance

Antivirals are important for easing the peak of illness and, as we can't identify who most needs them, a blanket approach is the only option, says Professor David Price. But Dr Helena Newman argues that the policy of blanket antiviral use is costing the NHS a fortune, inappropriately cosseting patients and risks fuelling drug resistance

GPs are increasingly arguing that the benefits of antivirals are too limited to merit their blanket use in everyone with swine flu symptoms. But when we look at the evidence for use of antivirals, there are two ways of assessing the benefits.

The first is to look at duration of illness. Here their effect might seem quite limited, in reducing length of symptoms by about half a day. But the second way is to look at the effect of antivirals on the peak of illness, which is really what we are aiming for in their use, and yet is often ignored. The evidence from analyses of bird flu outbreaks suggests antivirals, when given promptly, can be incredibly effective at preventing complications and deaths.

In any case, lack of evidence for the benefits of antivirals isn't sufficient reason not to provide them. If we waited for enough evidence we could find ourselves facing much more severe consequences than might otherwise have occurred.

The Government has little option but to stick to its policy of providing antivirals to everyone who feels they need them. After all, we're seeing deaths in young people with swine flu and unlike seasonal flu we don't yet have a vaccine. We also don't have good evidence for who is most at risk of infection and complications, which makes it difficult to draw up policies targeting particular groups.

We do know younger people seem at particular risk, since they appear to have no resistance to the virus, and it would be logical to assume some of those who would be in real trouble if they caught seasonal flu would also be at risk from swine flu. But at the moment, the risks of not offering treatment for everyone with symptoms seem to be greater than the risks of giving treatment.

Inevitably some patients will end up receiving the drugs inappropriately and in some cases may even make up symptoms to get them. But ultimately, people have to take responsibility for their own health and if they take drugs without really needing them, and expose themselves to risk of side-effects unnecessarily, that is their responsibility as long as the risks have been explained. The only alternative to the Government's current policy would be for GPs to test every patient with symptoms, and we don't have the time to do this.

There is a concern that such widespread use of Tamiflu will promote resistance to the drug, and there have been signs of some strains of flu becoming resistant to it. But actually, and rather bizarrely, there isn't good evidence that the development of resistance is linked to high levels of antiviral use. Japan uses antivirals extensively, perhaps inappropriately so, yet has low rates of antiviral resistance.

There is also no evidence that widespread antiviral use suppresses people's ability to develop resistance against the virus. If someone is exposed to flu and treated with antivirals, they still develop antibodies, and so will develop resistance in the normal way.

If we really want to reduce use of antivirals, the answer is not to change the policy on their use, but to look at public health measures for reducing the spread of swine flu. It is noticeable rates of the illness in the UK have dropped substantially now children are on their summer holidays. There is no greater way of facilitating the spread of swine flu than allowing children to mix in schools. It would in my view be potentially foolhardy to allow children back to school until we have adequate vaccination in place.

Professor David Price is General Practice Airways Group professor of primary care respiratory medicine at the University of Aberdeen and a GP in Norwich

What's in a name? I guess if you are a journalist, and want a really exciting story, you have to capture the public's imagination. So plain flu just isn't good enough. Yuppie flu sounded like something you'd want to catch, but swine flu - well, that's more like it. Everyone hates pigs.

To be fair to the journalists, though, it wasn't they who started this recent bout of mass hysteria. And it's not their responsibility to consider the clinical consequences of the use of medication on such an unprecedented scale.

The Government and the NHS have been planning for a flu pandemic for several years now, and it has all become a huge PR exercise. We hear of meetings galore, full of solemn planners agonising over their forecasts, worst-case scenarios and assessments of readiness. There is a lot of political mileage to be made and lost, and swine flu is a nice easy one, at least compared with some of the infections out there. I'd like to see them plan to control the spread of tuberculosis, HIV, malaria or chlamydia.

The hype starts with the language. NHS planners will 'roll out' their 'emergency strategies' to cope with a tsunami-like 'second wave' of infection.

And then there is the cavalier approach to funding. Drugs and services are frequently rationed but on this one, Joe Public needn't worry. The Government is quite happy to play the parent and you can have it all - Tamiflu on demand, online, on the telephone, free for everyone.

But Tamiflu is £15 per course and we're planning for 50 million or so flu vaccines at £5 plus per head. Then there are about 1,500 people working at the flu hotline call centre - all for what is basically, in the vast majority of people, a mild, self-limiting condition.

What message is this sending out to people? And is there going to be any money left over for those with more serious conditions?

We're not even sure that Tamiflu is working. Two studies out last week have questioned its effectiveness in both adults and children1,2. Yes, antiviral treatment shortens symptoms a little, but it doesn't appear to have much effect on more serious complications such as asthma flare-ups or ear infections.

And I think we are all concerned that such excessive use of antivirals will encourage the virus to develop resistance, just as bacteria have to antibiotics. Illnesses such as gonorrhea became resistant to penicillin quite quickly, and there are reports of the flu virus already showing resistance to Tamiflu.

The side-effects of Tamiflu are not insignificant, yet this drug is now being issued by non-medical staff over the phone, which is something nurse practitioners have not been allowed to do without extensive training in pharmacology. This has never happened before on such a scale in the history of medicine, and we naturally feel nervous about it.

For such a mild and brief illness, surely antivirals should be reserved for those at particularly high risk?

Meanwhile, the companies that make antibacterial hand gels are coining it in, and people are afraid to touch one another, just as they were when we first heard about AIDS. I was told the Archbishops of Canterbury and York have recommended not sipping from the communion cup, even though it is always wiped clean first, but dipping the bread instead. That is a measure that was last introduced when the country was overrun with bubonic plague.

Calm and old-fashioned common sense is what is required, rather than obsessiveness and overreaction. We are in danger of becoming a nation of neurotics.

Dr Helena Newman is a GP in Woking, Surrey

Tamiflu yes no

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