“If you get a resistant strain that becomes dominant in the autumn..”

Speaking of forms of press populism.. The Guardian has an interesting report on the UK government’s response to the H1N1 swine flu pandemic. Below the fold I sketch out an apparent divergence in strategy here – and it’s worth noting Mack’s thoughts on swine flu there. Meanwhile, according to the Guardian’s report

The government rejected advice from its expert advisers on swine flu, who said there was no need for the widespread use of Tamiflu and suggested that the public should simply be told to take paracetamol. An independent panel set up by the Department of Health warned ministers that plans to make the stockpiled drug widely available could do more harm than good, by helping the flu virus to develop resistance to the drug.

But ministers pressed ahead with a policy of mass prescription, fearing the public would not tolerate being told that the millions of doses of Tamiflu held by the state could not be used during a pandemic, one of the committee members has told the Guardian. “It was felt … it would simply be unacceptable to the UK population to tell them we had a huge stockpile of drugs but they were not going to be made available,” Professor Robert Dingwall, a member of the Committee on Ethical Aspects of Pandemic Influenza, said.

Updated below the fold – Diageo offered employees Tamiflu.It’s not clear how early that warning came, but according to the report the Committee on Ethical Aspects of Pandemic Influenza last met in May. And the report also notes calls to stop the national flu pandemic service.

The concern was seconded by flu expert Hugh Pennington, emeritus professor at Aberdeen University, who called for the national flu line to be shut down.

“I am concerned about the vast amount of Tamiflu that is going out almost unregulated,” he told the Guardian. “We are increasing the possibility that the flu will become resistant sooner or later. At the moment there is no desperate need for Tamiflu. We should be reconsidering its issue, rather than encouraging its use.

“I think we should stop the national pandemic flu service. It was put there for an outbreak of far higher mortality than we have. If you get a resistant strain that becomes dominant in the autumn, Tamiflu will then be useless.”

It’s worth noting that there appears to have been a divergence in policy here when compared to elsewhere in the UK. [added link]

In his earliest statement to the Assembly on 27 April, NI Health Minister, the UUP’s Michael McGimpsey, set out the initial response

“Testing has shown that the human swine influenza can be treated with antiviral drugs, which I am pleased to say that we have already stockpiled in Northern Ireland.”

Anti-virals, such as Tamiflu, were still the main focus of the NI Health Minister on 5 May

Given that it will take several months before a vaccine becomes available, we will in the interim need to ensure we have adequate supplies of antiviral medication, which is proving effective in treating this virus.

We currently have a stock of antiviral drugs which will cover half of the population. Steps are in place to increase this so that there will be sufficient antivirals to treat up to 80% of the population. No previous global pandemic has been known to affect more than a third of the population.

We have placed supplies of the antiviral medications in hospitals and in GP out of hours centres. In addition, measures are in place to ensure that an adequate supply of antiviral medication will also be available to community pharmacies.

And on 18 May, although a note of caution had emerged

We must be prepared for a potential further wave of the swine flu virus in the autumn, which may be more widespread. In light of this, it is essential, that we use our stock of antivirals carefully so that the public will be protected during the winter months.

That position was largely unchanged on 9 June but the focus on anti-virals remained and, arguably, intensified.

“I have therefore been working with my counterparts from the other UK Health Departments in developing the National Pandemic Flu Service. This system will co-ordinate the distribution of antivirals and has the capacity to cope with any surges in demand that are likely if the virus becomes more widespread.

“The National Pandemic Flu Service will be the first of its kind in the world and will be available from October.

“The aim is to enable symptomatic patients across the whole of the UK to access antivirals through a single 0800 number, or a supporting website application. This will mean people can have their symptoms assessed against a list of the key symptoms and risk factors either over the phone or online.”

By the 15 June the NI Health Minister’s position was unchanged but he was looking towards a mitigation strategy

“The mitigation strategy will mean that when the number of cases increases beyond a certain level, we will have to keep under review to what extent we supply antivirals to contacts —in the first instance supplying them only to immediate close contacts rather than to all contacts. This may also require the use of clinical diagnosis rather than laboratory testing where there is a high probability that cases are positive. A reduction in the numbers of follow-up contacts may also be necessary so we only target those who are most at risk.”

Significantly on 30 June, for the first time the NI Health Minister publicly considered changing the strategy ahead of a meeting “chaired by Andy Burnham, Secretary of State for Health in England. Health Ministers from Wales and Scotland also participate in this meeting, along with scientists and other senior health professionals including the four Chief Medical Officers.”

“As with seasonal flu, most otherwise healthy people generally do not require antivirals. What is more, antivirals can produce side effects such as vomiting, diarrhoea and nausea. The continuation of widespread use of antivirals also runs the risk of the virus developing resistance and so reducing the level of protection this treatment gives.

“Emerging clinical experience of this virus suggests that for many people, the symptoms of swine flu can be treated in the same way as a normal cold or seasonal flu, by staying at home; taking paracetamol and cold remedies to reduce symptoms; drinking fluids and resting and only contacting your GP if your symptoms are not improving.

“If we were to adopt this approach, as with seasonal flu, it would mean that we would rely more on symptoms rather than swabs to diagnose the illness. It would mean that the use of antivirals as a preventative measure and the tracing of close contacts of a symptomatic patient, would be largely discontinued, although that would be based on the clinical judgement of local clinicians.

“This is in line with what is currently happening in the US, Canada and Australia where there are large numbers of cases.”

On 2 July the Minister announced the outcome of that meeting

“The Scientific Advisory Group in Emergencies (SAGE) has considered this question and reports that on balance the science points towards adopting a targeted approach, but acknowledges that this is a ‘finely balanced’ decision. Health Ministers are also conscious that, as this is a new virus, it cannot yet with confidence be directly compared to seasonal flu. Given this, we have decided to adopt a safety first, precautionary approach. Antivirals will continue to be offered to people who have contracted swine flu.”

And, perhaps with an eye on the possibility of adverse publicity, the first apparent divergence in strategy came not from the Health Minister, but on 24 July from the Acting Chief Medical Officer, Dr Elizabeth Mitchell whose statement notes that the National Pandemic Flu Service “is only available to people living in England or registered with a GP in England.”

“The current numbers of GP consultations in Northern Ireland for flu are still relatively low. The present arrangements remain the best and most appropriate way to get treatment to anyone who needs it. Northern Ireland will be able to use the National Pandemic Flu Service if the need arises at a later date. This situation is being kept under constant review.

“To avoid spreading the virus, people who think they have swine flu should stay at home and take simple measures to alleviate their symptoms such as rest, drinking plenty of fluids and taking paracetamol as required. If anyone is still concerned, and in particular, if they are in a higher risk group they should contact their GP.”

And on 30 July the Acting Chief Medical Officer, again, confirmed that change in strategy

“If you think you have swine flu stay at home, please do not visit your GP practice or A&E in person. For otherwise fit and healthy people, there is usually no need to take antivirals. Most people will recover at home by taking simple measures to alleviate symptoms such as resting, taking paracetamol and drinking plenty of fluids. If, however, your condition suddenly deteriorates or is getting worse after seven days (five for a child) then you should contact your GP or out-of-hours service.

“People with underlying health conditions who are at higher risk of complications if they develop influenza should call their GP for advice and assessment for antivirals.”

On 8 August the Health Minister made a statement assuring the public that Tamiflu remained available as a treatment, although the actual quotes don’t quite match the introduction.

Mr McGimpsey said: “The Public Health Agency in Northern Ireland is working closely with colleagues in the Republic of Ireland to ensure that all symptomatic children receive Tamiflu, if appropriate and, that parents are advised of the situation.” [added emphasis]

The new NI strategy remains in place as of 13 August.

And the vaccine, when available, will be similarly targeted.

Adds RTÉ reports that – “Drinks group Diageo has confirmed that it has offered its 2,000 Irish employees a free course of anti-viral medication [Tamiflu] to treat influenza.”

Free or subsidised anti-viral medication has also been offered to designated members of employees’ families, as part of the measure, which has also been introduced for its employees worldwide.

In a statement, Diageo Ireland, whose brands include Guinness and Budweiser, said that the most important priorities are ‘to protect our people, their families and our business operation’.

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  • I’m reminded of the South Park episode:

    “We have SARS! We have only a 98% chance of survival!”

    Eventually they find the cure for SARS is chicken soup…

    Seriously though.

    I’m glad to see the tide turning against mass treatment and more towards a case-by-case approach. I’m disappointed in Diageo, who appear to be swimming against the tide here. It is all too easy to pander to the public’s concerns through overtreatment rather than reassurance.

  • Dave

    “I think we should stop the national pandemic flu service. It was put there for an outbreak of far higher mortality than we have. If you get a resistant strain that becomes dominant in the autumn, Tamiflu will then be useless.” – Hugh Pennington

    The flaw here is that national agencies are still thinking nationally about a pan-national epidemic despite the proliferation of policies that allow free movement of people between international jurisdictions and thereby allow the rapid spread of infections between them. So if one jurisdiction implements an immunisation policy that allows for a new Tamiflu resistant flu virus to develop, then that new virus will infect other jurisdictions irrespective of what the immunisation policy was in those other jurisdictions.

    They either have to roll back on ‘globalisation’ or transfer the applicable sovereignty to a global health agency along the lines of the WHO that will implement policy in all jurisdictions.

  • LGO

    Dave, you’re spot on. There are many factors that make this different from the 1918 outbreak – war, hygiene, housing etc, but the one thing that works in the favour of the spread of anything like this is global travel.

    Interesting reading also – will get the link later – is the outbreak figures. Specifically the country by country breakdown. Either the UK is “over-reporting” – hence the “spike” – or just about every other country is very lax.

    Panic is not really pertinent at this relatively quiet time. But the business continuity issues should a real outbreak happen could be worth looking at. Not that we’re in, or heading towards, mass graves or anything, but a serious outbreak leaving a small business with, say, 50% of its staff off presents a big problem.

    There’s another interesting paper hiding abouthe the place, about the distribution of tamilflu in a Northern Ireland context…but that’s for another day.

  • borderline

    What an excellent blog by Pete Baker.