Medical Ethics and the pandemic flu [Archive]

Dymanic

5th May 2007, 01:24 AM

This is actually part of a broader question -- or maybe it's an entire class of questions. The built-in assumption: "There is currently no significant incidence of influenza and no shortage of Tamiflu" makes things a little easier to address, since it limits the issue to concerns about resistance -- though that is no simple matter by itself. If you're interested in antiviral resistance in particular, I'd recommend a bit of reading:

http://scienceblogs.com/effectmeasure/2007/03/modeling_antiviral_resistance_1.php#more

If you're more interested in the broader question, I'd say it has to do with the physician's responsibility to a single patient versus his responsiblility to... unknown numbers of patients; hundreds; maybe thousands. In the teeth of a pandemic, caregivers will face tough choices, just as they often do in any emergency. Think of battlefield triage; the price of time spent treating a hopeless patient may be the life of one who might have been saved. If the goal is to save as many as possible, this must be kept in mind when allocating any resource.

Here, (given the framing of the question) that resource, as I see it, is susceptibility of the virus to the drug. Ideally, this resource would be conserved in such a way as to give the greatest possible number of people a chance of being effectively treated. Doing that may mean asking difficult questions like: which patients are at greatest risk? and: Which stand to benefit most? and maybe: Which ones are at greatest risk of passing the virus on to others? and, perhaps most difficult of all: Which ones are the most indispensible due to the importance of their roles in society?

If this were the planet Vulcan, we could maybe use our superior logic to neatly quantify all of that and act accordingly (though if you read through the lengthy series of posts that start with the above link, you'll see that even if a strategy for antiviral deployment could be consistently implemented -- enforced, I guess it really is -- there isn't any single obvious strategy that just jumps right out at you). Here on Earth, the identifiable needs of the patient right in front of you -- the one with a face, and a name -- are likely to carry more weight than vague concerns about the needs of an unknown number of patients you've never met.

Isn't there a shelf-life issue as well?Antiviral drugs have a pretty decent shelf life compared to most pharmaceuticals. Roche has it at 36 months for Tamiflu, and it's probably better than that if kept properly. With the other class of antivirals, Amantadine/Rimantadine, it's even better. I've seen it quoted as better than five years.

skepticdoc

5th May 2007, 07:54 AM

I imagine it was posted in a physician's only listserve because the question only pertains to real physicians. So what's your point in asking us?

This is more of an ethics/philosophy issue, I posted initially in the Religion section, some moderator moved it!

Do you have an opinion?

Slimething

5th May 2007, 01:32 PM

Do you have an opinion?

No opinion, sorry. I don't have the expertise. Perhaps if you explain your purpose in asking the question, you would get more informed people than me replying.

Dymanic

5th May 2007, 02:17 PM

No opinion, sorry. I don't have the expertise. Is there any of us who can claim "expertise" concerning what is right and what is wrong?

"And what is good, Phaedrus, And what is not good -- Need we ask anyone to tell us these things?"

Slimething

5th May 2007, 05:06 PM

Dynamic, I could offer an opinion if I knew the facts surrounding the question. You are not the OP so I can't really say that the foundation you've described is what the OP had in mind. Thus, I've asked the OP to expand informatively on his question.

So, what was Phaedrus' answer? :biggrin:

Wat Tyler

5th May 2007, 05:31 PM

As a Brit, living in a country with a state-funded healthcare system, my first response is the facile 'NHS GP's can NOT sell-on medicines anyway :p '

But, with my non-facetious hat on:

As others have intimated, there are two problems with selling the 'gear' to the patient:

1) this action may well expedite the evolution of drug-resistant strains of the virus, and as such probably contravenes the Hippocratic Oath that Doctors swear;

2) what if the medication proves ineffective against the particular strain that causes the pandemic anyway?

Of course, with my Evil hat on:
I box a bunch of aspirin up as Tamiflu, sell him (and everyone else who asks) that, and then retire to my private island to sit out the pandemic - bwahahahahahahahahah!

skepticdoc

5th May 2007, 05:38 PM

In the U.S. most Physicians do not sell medications.

Federal law requires a prescription to buy the medication from a drugstore.

Wat Tyler

5th May 2007, 05:45 PM

In the U.S. most Physicians do not sell medications.

Federal law requires a prescription to buy the medication from a drugstore.

Cheers.

To clarify (because I forgot to include this bit in my last post. D'oh!), were I a Doctor, I would refuse to sell him the prescription, for the reasons that I put in my last post - it might not work anyway (so I'd be ripping-off a trusted patient), and doling it out may, in fact, precipitate a more-serious pandemic later on.

What is/are your answers to the question?

If you are on a Physicians-only list, I presume that you are one, and have taken the Hippocratic Oath.

Does the Oath affect your answer to the question?

Gurdur

5th May 2007, 06:00 PM

...were I a Doctor, I would refuse to sell him the prescription
To point out this again and more generally:

Physicians commonly do not sell prescriptions.

So if you post again on this, please change it to, "I would refuse to write him a prescription" or "I would refuse to prescribe it".
If you are on a Physicians-only list, I presume that you are one, and have taken the Hippocratic Oath.
Does the Oath affect your answer to the question?
Most or many USA physicians do not take the classical Hippocratic Oath. UK docs do not take it at all. In general, the Hippocratic Oath has been succeeded in many places by the Declaration Of Geneva (http://en.wikipedia.org/wiki/Declaration_of_Geneva).

Here is the UK GMC Duties Of A Doctor (http://www.gmc-uk.org/guidance/good_medical_practice/duties_of_a_doctor.asp), and also the GMC Good Medical Practice (http://www.gmc-uk.org/guidance/good_medical_practice/index.asp) guidelines.

Just as well, or any doc operating on you for kidney stones would be contravening the classical oath.

Wat Tyler

5th May 2007, 06:08 PM

To point out this again and more generally:

Physicians commonly do not sell prescriptions.

So if you post again on this, please change it to, "I would refuse to write him a prescription" or "I would refuse to prescribe it".

Ah, OK.

Would you write the requested prescription?

Most or many USA physicians do not take the classical Hippocratic Oath. UK docs do not take it at all. In general, the Hippocratic Oath has been succeeded in many places by the Declaration Of Geneva (http://en.wikipedia.org/wiki/Declaration_of_Geneva).

Here is the UK GMC Duties Of A Doctor (http://www.gmc-uk.org/guidance/good_medical_practice/duties_of_a_doctor.asp), and also the GMC Good Medical Practice (http://www.gmc-uk.org/guidance/good_medical_practice/index.asp) guidelines.

Just as well, or any doc operating on you for kidney stones would be contravening the classical oath.

OK, then I'll rephrase my previous question:

Would writing the requested prescription contravene any terms of any of the documents you mentioned?

(I'd guess that it wouldn't directly contravene any, otherwise skeptidoc's original question would never arise.
But I'd still be interested in getting the opinion of a qualified person.)

Gurdur

5th May 2007, 06:17 PM

Ah, OK.
Would you write the requested prescription?
Sometimes yes, sometimes no. I'm answering generally.

This question is far more tricky than is thought. What is the patient is depressive and in an anxiety state? Tons more interesting ways the situation can be made more complex. Normally, I personally would try hard arguing any such patient out of such a thing.

Caveat: although I was involved in one of the ancillary medical sides of life, diagnosis, treatment, and rehab of aphasiacs, apraxics and some other neuro disorders, I personally do not have the authority to issue prescriptions, so you might like to discard my opinion.
Would writing the requested prescription contravene any terms of any of the documents you mentioned?
Depends who you talk to. Really. This is a nasty complex area. And you will find quite a large cultural medical difference between the USA and the UK on this.

To make your question sharper, you could ask:
Could a physician be disciplined by a medical council in the UK for committing such an act?

I believe perhaps; it really would depend on the mood everyone was in at the time. One of those issues that can fall either way depending on politics of the day, mood and interpretation of the guidelines.

Wat Tyler

5th May 2007, 06:39 PM

Depends who you talk to. Really. This is a nasty complex area.

I've occasionally encountered such issues in my own working life.

When asked for my opinion on complex and vaguely-regulated matters such as this, I have found it best to respond with something like "this is a particularly penumbracious area - it would probably be best to verge on the margins of prolixity in your report" - and to then skedaddle before they can work out what I've just said.

Or to boot the issues upstairs for 'clarification' - which, as often as not, will then meet with the same sort of evasive waffle.
:D

Dymanic

5th May 2007, 08:37 PM

I could offer an opinion if I knew the facts surrounding the question.
I'm not sure that the question can be answered solely on the basis of facts anyway. It's similar to the dilemma posed by certain problem pregnancies which may place the mother's life at risk; aborting the fetus is not as straightforward a decision as removing an inflamed appendix. Sometimes, the best interests of the patient are not the only thing to consider.

That last is actually quite an understatement. In the current environment, economics are too often the first thing that must be considered. A clinician who is under pressure from an HMO to hustle patients through the exam room in ten minutes or less is doing good to get at the salient medical facts, much less get into tricky ethical questions. A patient with minor symptoms may exert further pressure on the clinician: he wants an antibiotic. The quickest way to get rid of him may be to simply give it to him; after all, it might turn out to be bacterial. This could be confirmed by culture, but who's gonna pay for that? To withhold treatment incurs certain risks as well; a lot of folks make a good living on malpractice lawsuits. When the end result of all this is antibiotic resistant pathogens, who is responsible?

The question about antivirals might be restated as: would you prescribe any drug knowing that doing so is likely to contribute to the problems we're already having with resistant pathogens, and might not be of much benefit to the patient anyway? If the answer is no, the next question is: would you hold to this policy even if it compromised you professionally?

So, what was Phaedrus' answer?My favorite answer is: no, we merely need someone to show us that we already know.

Slimething

5th May 2007, 10:37 PM

In the U.S. most Physicians do not sell medications.

To point out this again and more generally:

Physicians commonly do not sell prescriptions.

Gurdur, is skeptidoc your sock? That would explain a lot about the reception skeptidoc has gotten here from other members who are health professionals.

Slimething

5th May 2007, 10:46 PM

That last is actually quite an understatement. In the current ... When the end result of all this is antibiotic resistant pathogens, who is responsible?

Dynamic, from the style and content of what you write, I take it you are a physician. If so, I can only tell you that I would dread being in your shoes sometimes. Yes, I face ethical problems sometimes but my decision do not result in any meaningful change in anyone's lives. As far as the more difficult choices you have to make, I, like Phaedrus, can be of little help.

If the answer is no, the next question is: would you hold to this policy even if it compromised you professionally?

I read the Hippocratic Oath after your first answer and some of the versions I read were a bit nebulous as to whom you "would do no harm". I would probably tell my patient no and tell them the reasons. If the patient was intelligent, they would understand. If not, let natural selection take its course. (Isn't that truly horrible? Maybe that's why I'm not a physician!)

skeptigirl

5th May 2007, 10:56 PM

I imagine it was posted in a physician's only listserve because the question only pertains to real physicians. So what's your point in asking us?
Skepticdoc has his own secret "Dr only" forum on the Skeptic forum user groups. My guess is no one posts there. He gets bored.

While I was over there looking for a link to the user groups I came across this thread on the MSNBC article (http://www.skepticforum.com/viewtopic.php?p=102583#102583) on how long cells really live after the heart stops and that brain cells die when the O2 returns. Skepticdoc made more classic comments implying once again only doctors know anything....NOT! ;)

skeptigirl

5th May 2007, 11:57 PM

Back to the topic...

There are an number of things to point out here.

First, they are using Tamiflu like crazy in the countries experiencing actual H5N1 human cases. Some use is called for like when one person in a family gets bird flu you do want to give Tamiflu to the other family members and close contacts. And they've tried to use the Tamiflu to save lives. But it needs to be given in the first 48 hours after symptom onset since it is most effective aborting a case and less effective treating a case. In the part of the world experiencing human cases they are often only detecting the cases once people are real sick and come to the hospital, typically well past 48 hours.

In addition, some countries are using Tamiflu for regular flu. It can be prescribed for any case of flu and some health care providers prescribe it more often than others. After all, that's what the company selling it wants you to do. So of course they are advertising there is no shortage. OTOH, the longer it takes for a pandemic strain to develop, the larger the Tamiflu stockpile is, so they aren't wrong to say there is currently plenty.

A few cases of mild drug resistance have developed in H5N1 strains but so far it hasn't been widespread. Even if drug resistance develops in other flu strains, the genes might find their way to the H5N1 strain. Resistance is however, inevitable eventually. And it is hard to predict if drug resistance will mainly be a function of prior to the pandemic use or use during the pandemic. I don't think it's an issue for deciding to prescribe or not prescribe a family stockpile at this time.

A more important issue is wasting the supply. If the user isn't able to distinguish flu symptoms from other viral illnesses, they'd be likely to take the drug for the wrong infection. People will panic if they get sick during a pandemic. Yet other infections don't stop during a pandemic. As far as expiring, that would happen no matter whose shelf it was stored on. And those people with expired drug should still use it if there isn't enough to go around. It might still save lives. We don't know but it is only logical to keep it in this case.

From a public health standpoint, if the PHD controls the Tamiflu supply they'll be able to use it for contacts of H5N1 cases and more effectively control the outbreaks during a pandemic. They did a good job controlling SARS by that very means.

From an individual doctor's standpoint, they are most likely to waste Tamiflu on critically ill patients for whom they want to do something but for whom the benefit is doubtful. But tell that to the parent of a dying 12 yr old. So you can see why the doctors are likely to waste doses.

For the health care workers, there is going to be a dilemma if they are given Tamiflu to protect them so they can take care of infectious patients if the health care worker's family doesn't have access to Tamiflu. Do you take it or pocket it and give it to your kids?

From an individual's point of view, you can either trust the public health to do the most good for the most people and take your chances. Or you can decide that your own family comes first. If there is a shortage, how will you feel if people with access to Tamiflu who don't fall on the distribution priority list take some for themselves and their family? How will you feel if the governor's children get some when only the governor is on the list? Does the queen get some? Can Bill Gates get some?

The scenario could get ugly.

You can get by without Tamiflu if there isn't any. You will be safe if you can just stay home, and when you do go out for food and necessities, wear a good mask, don't get close to people and wash your hands well. We know a lot more about preventing disease transmission now than we did in 1918.

As a health care provider now, before the pandemic, I am inclined to write the prescriptions. If the alert level goes to 5 (http://www.who.int/csr/disease/avian_influenza/phase/en/index.html) or starts approaching 5, I would no longer write the prescriptions unless there was an adequate supply. At that time the public health would probably order providers not to prescribe or what conditions to prescribe under anyway. They did that a few years ago with flu vaccine during a shortage. Even though I had a private practice and vaccine in stock, our county issued an order restricting who I could vaccinate.

But with the pandemic risk progressing at a slow steady pace, I think prescribing it now for the patient to keep on hand is within that patient's rights and why should I be in the role of gatekeeper? If a public health order says I should gatekeep, then I should. But on principle, I think the principle of patient's right to choose is higher than my need to second guess future public health needs.

Gurdur

6th May 2007, 03:43 AM

.... Skepticdoc made more classic comments implying once again only doctors know anything....NOT!
Hmmm. I couldn't give a stuff about whatever feud you have going on with him; but it's totally irrelevant to the OP etc., and you have no valid excuse here for dragging yet another thread off into your weird little derails, so drop the childish nonsense and stay on topic, mmmmkay?

Dymanic

6th May 2007, 09:27 AM

Dynamic, from the style and content of what you write, I take it you are a physician.One of the most remarkable features of the human brain is its ability to create pieces of information and use them to fill in the gaps between known pieces of information. If only it could do so with better accuracy!

As far as the more difficult choices you have to make, I, like Phaedrus, can be of little help.I'd like to encourage you to make your best effort. I mean, it's good to be humble and modest and all that, and there are undoubtedly many who could benefit from taking your reserved approach to the forming of opinions in the face of incomplete information -- but I think that at some point there is a certain obligation to join the struggle, whatever that entails. The alternative is to let others make difficult decisions in your name.

But it's not just that. In the throes of a global pandemic, physicians aren't the only ones likely to face difficult choices. You've stockpiled food; your neighbors are starving; what to do? From the comfort of an armchair, you can decide what kind of person you want to be -- but once the **** hits the fan, it's not so much about deciding; it's about finding out what kind of person you are.

Dymanic

6th May 2007, 09:41 AM

From a public health standpoint, if the PHD controls the Tamiflu supply they'll be able to use it for contacts of H5N1 cases and more effectively control the outbreaks during a pandemic. They did a good job controlling SARS by that very means.That approach might work at the very first emergence of a pandemic strain, but there won't be any controlling outbreaks during a pandemic. Flu can't be compared to SARS. Flu is profoundly contagious. It's contagious before the onset of symptoms, and it's airborne. Once a pandemic is underway and affecting millions of people, public health policy becomes a matter of minimizing social disruption.

From an individual doctor's standpoint, they are most likely to waste Tamiflu on critically ill patients for whom they want to do something but for whom the benefit is doubtful.Battlefield triage.

From an individual's point of view, you can either trust the public health to do the most good for the most people and take your chances. Or you can decide that your own family comes first.
There it is.

In a sense, it is like the question (which surprisingly many people find difficult) of whether or not to vaccinate. As more people are vaccinated against an illness, even the individual who is not vaccinated enjoys a reduced risk of aquiring that illness. There being always a certain risk of adverse affects from any vaccine, a point is reached at which the risk from the vax may actually be greater than the risk from the disease. Herd immunity may be viewed as a collective responsibility, but it's hard to fault anyone for making decisions based on what they think is in their own best interests. Here, the question is: should the physician support the individual who decides that he and his family come first?

If the alert level goes to 5 or starts approaching 5, I would no longer write the prescriptions unless there was an adequate supply. At that time the public health would probably order providers not to prescribe or what conditions to prescribe under anyway. They did that a few years ago with flu vaccine during a shortage. Even though I had a private practice and vaccine in stock, our county issued an order restricting who I could vaccinate.I'd say that what it amounts to is that there can be a conflict of interest between those who are attempting to protect individual patients and those who are attempting to protect entire populations.

But with the pandemic risk progressing at a slow steady pace, I think prescribing it now for the patient to keep on hand is within that patient's rights and why should I be in the role of gatekeeper?
Nice to see someone step up with an actual opinion. Would you have any recommendations to the patient regarding its use (as prophylaxsis versus treatment)?

Slimething

6th May 2007, 12:53 PM

One of the most remarkable features of the human brain is its ability to create pieces of information and use them to fill in the gaps between known pieces of information. If only it could do so with better accuracy!

So, I'm wrong! This is the very reason I won't make decisions without doing my due diligence.

I'd like to encourage you to make your best effort. I mean, it's good to be humble and modest and all that, and there are undoubtedly many who could benefit from taking your reserved approach to the forming of opinions in the face of incomplete information -- but I think that at some point there is a certain obligation to join the struggle, whatever that entails.

Dynamic, I'm a scientist. What you take as humility and modesty is a life-long devotion to my discipline. I cannot give you a decision or opinion on the OP without considering all the facts and I'm too busy to do this.

The alternative is to let others make difficult decisions in your name.

I do that every day. So do you.

You've stockpiled food; your neighbors are starving; what to do?

Mmmm. Neighbors. Mmmmm. :D

Slimething

6th May 2007, 01:10 PM

Hmmm. I couldn't give a stuff about whatever feud you have going on with him; but it's totally irrelevant to the OP etc., and you have no valid excuse here for dragging yet another thread off into your weird little derails, so drop the childish nonsense and stay on topic, mmmmkay?

Gurdur,

You have unwittingly (as is your usual mien) provided evidence that you and skepticdoc are one in the same poster. Either explain the strange circumstance of skepticdoc saying one thing and then your arriving saying that you must again say what skepticdoc originally said or both of you will be considered to be what most of us consider you to be already. Where is a Moderator when you need one?

Anyway, you are not the OP (take that back, actually you are!) and you certainly don't get to play Almighty Moderator of whatever thread you're in. Your complaining that another member is unjustified in providing background on another member who has, so far, not answered essential questons about what he's written is not warranted and what Skeptigirl has contributed is not irrelevant to the thread. Moreover, your famous hypocrisy and illogic comes into play for doing what you got after her for in the first place by chiding her for "your weird little derails".

I have no idea why you're creating socks in this forum. You must believe that the rest of us are stupid enough to think, "Hey, this guy's posts are similar to gurdur's but we respect this numbskull only because his name doesn't begin with G!"

Gurdur, an idiot is sitll an idiot by any other name. As far as I know, your net contribution to society is merely coining two additional synonyms.

skeptigirl

6th May 2007, 02:07 PM

Originally Posted by skeptigirl
From a public health standpoint, if the PHD controls the Tamiflu supply they'll be able to use it for contacts of H5N1 cases and more effectively control the outbreaks during a pandemic. They did a good job controlling SARS by that very means.

That approach might work at the very first emergence of a pandemic strain, but there won't be any controlling outbreaks during a pandemic. Flu can't be compared to SARS. Flu is profoundly contagious. It's contagious before the onset of symptoms, and it's airborne. Once a pandemic is underway and affecting millions of people, public health policy becomes a matter of minimizing social disruption.We really don't know. But the most likely scenario is the virus will begin person to person transmission under intense scrutiny by the WHO. The degree of spread at time of detection will have an impact on whether or not it can be contained. It may not be picked up soon enough or due to lack of public health infra structure depending on where the outbreak occurs, chances are pretty high it won't be contained at that point.

But in the initial phase, whether that is weeks or months, the public health in developed countries will be able to contain the disease. We do it all the time. You isolate and treat everyone who has had exposure to the patient. People are not infectious until they incubate the disease so you don't have to treat contacts of contacts unless one of those initial contacts becomes a case.

At some point in time, though, the number of cases outside of the country will result in too many cases entering the country and the system will reach it's capacity to contain it. Had this all occurred a year ago, the public health control of Tamiflu could have been a critical factor. If it doesn't occur for 2 or 3 more years, there will be enough Tamiflu generally that perhaps only local shortages will be an issue. Public health in the US wasn't good at distribution when the flu vaccine shortage occurred. It was a system problem I won't bore you with.

Originally Posted by skeptigirl
From an individual doctor's standpoint, they are most likely to waste Tamiflu on critically ill patients for whom they want to do something but for whom the benefit is doubtful.

Battlefield triage.You missed my point. It isn't triage, it's misguided compassion.

Originally Posted by skeptigirl
From an individual's point of view, you can either trust the public health to do the most good for the most people and take your chances. Or you can decide that your own family comes first.

There it is.

In a sense, it is like the question (which surprisingly many people find difficult) of whether or not to vaccinate. As more people are vaccinated against an illness, even the individual who is not vaccinated enjoys a reduced risk of aquiring that illness. There being always a certain risk of adverse affects from any vaccine, a point is reached at which the risk from the vax may actually be greater than the risk from the disease. Herd immunity may be viewed as a collective responsibility, but it's hard to fault anyone for making decisions based on what they think is in their own best interests. Here, the question is: should the physician support the individual who decides that he and his family come first?You exaggerate the role herd immunity plays in determining risk vs benefit in the question of whether or not to vaccinate. While herd immunity is very important in overall disease reduction, you have to have an extraordinarily high risk of adverse outcome such as an allergy to a vaccine component before the risk of vaccinating outweighs the risk of disease. Herd immunity is then all you have left to rely on.

If you think herd immunity is a reason to forgo a routine vaccine because the risk of disease becomes small enough that the risk of vaccine now out weighs it, chances are you have an inflated perception of the risk of the vaccine or an inflated perception of how safe herd immunity makes you. It's that fact we live in a global community the very thing you say will make us unable to control a flu pandemic, that makes herd immunity imperfect.

When we reach the point where vaccines approach elimination of a disease, that is where vaccine risk begins to be greater than disease risk.

Originally Posted by skeptigirl
If the alert level goes to 5 or starts approaching 5, I would no longer write the prescriptions unless there was an adequate supply. At that time the public health would probably order providers not to prescribe or what conditions to prescribe under anyway. They did that a few years ago with flu vaccine during a shortage. Even though I had a private practice and vaccine in stock, our county issued an order restricting who I could vaccinate.

I'd say that what it amounts to is that there can be a conflict of interest between those who are attempting to protect individual patients and those who are attempting to protect entire populations.To some extent, but if there is a shortage of Tamiflu and it is the only protection against a deadly flu strain, you may actually be safer if the public health controls the disease. For one, slowing the pandemic down allows more time for vaccine production which is going to be more effective than Tamiflu. And for two, you might use all your Tamiflu up post exposure, but if the exposure threat continues, you'll be re-exposed and have no more Tamiflu.

It really is a complex issue and attempting to boil it down to the individual vs the community good is not without caveats.

Originally Posted by skeptigirl
But with the pandemic risk progressing at a slow steady pace, I think prescribing it now for the patient to keep on hand is within that patient's rights and why should I be in the role of gatekeeper?

Nice to see someone step up with an actual opinion. Would you have any recommendations to the patient regarding its use (as prophylaxsis versus treatment)?With abundant supply, prophylaxis. With limited supply, take it at the onset of fever >101 (assuming the pandemic is in full swing and you have no time to get a rapid flu test at your medical clinic.)

While the latter choice means risking the flu, there is no way to predict the length of time you would need prophylaxis and whether or not your supply would last.

Just for an update if anyone is interested. H5N1 continues to mutate and continues to spread, mainly in bird populations. The area where it has become endemic in bird populations reaches across Asia, to the edge of Europe and south as far as Ghana and Nigeria. The Middle East has had local outbreaks including Turkey, Saudi Arabia, Iraq and Iran. Egypt has had a number of outbreaks.

Indonesia has had the most human cases. And studies don't seem to show undetected human cases are significant, though there are many countries now where it's likely human cases will go undetected. And China waxes and wanes in their disclosure habits.

The only clusters involving person to person spread seemed to be in blood relatives suggesting a genetic factor at play. No human to human transmission has gone beyond tertiary transmission. In other words it spread from one person who then infected another who infected one more but then no more after that.

But there are now several "clades" or branches of the virus and it is maintaining its lethality. The virus has re-assorted a couple of times as well, mixing the genes in different clades of H5N1.

These have spread across regions sometimes more than once. A lot of spread is due to human transport of poultry, poultry products, and occasionally exotic birds. A little of the spread occurs via wild bird migration.

No mutations have suggested increased pandemic risk but the number of mutations needed is very small. This was determined by looking at the gene which would allow the virus to more easily replicate in human cells. Human flu and H5N1 were compared and the critical changes are only a few nucleic acid substitutions.

We have never observed a pandemic in the making like this before. No one has a clue if this is it and it just takes a while longer than we thought, or the next deadly pandemic will pop up out of some place we weren't looking. We do know from history it's when and not if.

The principles of infection control are what will save people. Drugs are nice, if they are available. But the movie version where this thing just spreads regardless of staying home is just nonsense. Infectious organisms behave in predictable ways and we know what those ways are. If a pandemic gets going and there is no treatment, stock up on food and stay home. Use what we know about infection control when you do have to go out. If you have to go out, use what we know about infection control in the house as well in case someone does bring it home.

Eos of the Eons

6th May 2007, 03:08 PM

If everyone just stays home, then how will we keep supplies of food and water available?

In the case of food, who will drive the supply trucks, and who will stock the shelves?

In the case of water, who will man the water treatment plants and keep it flowing through the pipes?

How will we keep gas and electricity going for our homes if people stay home from places that keeps that supply up? How will we keep water lines from freezing if our homes have no way to remain heated?

If we plan on staying home, then we'll need to stockpile food and water now, start building fireplaces into our homes, and stockpile wood. Plan on canned food, since no electricity means that your frozen food will be toast in those freezers that are plugged in.

It's plus 15 degrees celsius outside right now, and my toes are still cold. I don't have a fireplace. I'm chilly, but it's not cold enough to keep food from spoiling. If it is the middle of winter, food can be frozen outside, but I'll need a way to keep warm and cook food inside.

Once we make the available spaces in our homes for all that provision, how many days/months should we stockpile for? How much water per day should be on hand per person?

I'm quite certain I won't have the storage capacity for more than a week of supplies to keep 5 people alive. Rationing is a foreign concept to the kids, I'm sure.

We have a river nearby. I'm sure I could boil water if I chop down a few trees... if I'm allowed to go and chop down a tree in town, that is.

Let's just hope we can curb an outbreak quickly. There's too many people jammed into cities to have them all stockpiling for a pandemic? Or should I just start anyways?

skeptigirl

6th May 2007, 03:13 PM

Perhaps you were composing while I was editing.

"Use what we know about infection control when you do have to go out. If you have to go out, use what we know about infection control in the house as well in case someone does bring it home."

I could have put a whole piece in there about essential services and how to protect yourself when out but my posts are already so long I'm sure most people skip them as it is. ;)

Eos of the Eons

6th May 2007, 03:19 PM

Is there any source that has some answers on how long we should plan on not having essential services?

skeptigirl

6th May 2007, 03:48 PM

Is there any source that has some answers on how long we should plan on not having essential services?
In the US and I imagine in Canada, we have extensive plans in place that include businesses which provide essential services. I don't foresee the country coming to a halt under most circumstances. You could expect non-essential services to stop and public places to close. You might be advised to care for the sick at home and not bring them to overburdened hospitals.

Look at your local pandemic flu plans and see how thorough they are. King County has fairly detailed plans which include maintaining services in a labor shortage, who gets sent home, and so on.

Private industry has been invited to our regional pandemic flu planning conferences. And our public health has offered to work with them including planning and education.

I can't say we are perfectly prepared, but we are at least moderately well prepared around here.

Handwashing, staying 3 feet away, and droplet protection measures all should prevent a fair number of flu cases. The big problem areas are going to be overcrowded hospitals and people ignorant of basic protection measures.

Eos of the Eons

6th May 2007, 04:08 PM

Ivor the Engineer

6th May 2007, 04:19 PM

Though I thought it over-dramatised the issue, last year on BBC2 there was a Horizon docudrama on pandemic flu.

On the documentary side they interviewed scientists modelling the spread of the outbreak with and without the use of antivirals. Under some circumstances the only benefit of antivirals was to delay the onset of the pandemic by a few months. IIRC the total number of cases of flu was not significantly altered. This (http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0040013) article has more info. under what conditions antivirals may be used effectively.

I find it ironic that the likely cause of the spread of the virus to humans (poultry) will be involved in the preventative treatment. (Flu vaccinations are produced by incubating the modified virus in eggs.) Almost homeopathic:D

IMO a doctor should not prescribe antivirals for a healthy (but paranoid) patient.

skeptigirl

6th May 2007, 04:28 PM

...

I find it ironic that the likely cause of the spread of the virus to humans (poultry) will be involved in the preventative treatment. (Flu vaccinations are produced by incubating the modified virus in eggs.) Almost homeopathic:D

IMO a doctor should not prescribe antivirals for a healthy (but paranoid) patient.You are confusing a prescription to have on hand (which we do all the time) with one for someone who wants to take it now but doesn't need it.

Regarding the flu vaccine grown in eggs, it's a double whammy. If the virus kills the eggs we can't make vaccine. Or if there is a shortage of healthy chickens to provide the eggs we can't make vaccine.

skeptigirl

6th May 2007, 04:31 PM

Whew, at least there's some planning on the whole thing. If I stay home, then it won't be any big deal to keep my kids home for a few days/weeks if we can still find some sources of food (canned at home or whatever), and water is still availabe via the tap.

Is it a few weeks or months that they are looking at?

I wouldn't care if anyone tried to stockpile tamiflu. Most people won't know when to take it, since they will have no idea when they personally will be exposed, if at all.

Once you are actually exposed, tamiflu is not really useful right?

I'd prefer to stick with preventative measures.We have little to go on the predict the length of a pandemic. In 1918 it came in several waves lasting a couple months each.

Looking at the pandemic flu plans:

The Canadian Pandemic Influenza Plan for the Health Sector (http://www.phac-aspc.gc.ca/cpip-pclcpi/index.html)

BC Pandemic Influenza Preparedness Plan (http://www.bccdc.org/content.php?item=150)

King County: Pandemic Flu - Resources for businesses and community organizations (http://www.metrokc.gov/health/pandemicflu/businesses/)

It appears we have a tad more for business and industry where the BC plan focuses only on health care. Perhaps there were other Canadian plans elsewhere to be found.

Dymanic

6th May 2007, 04:39 PM

I'm a scientist. What you take as humility and modesty is a life-long devotion to my discipline. I cannot give you a decision or opinion on the OP without considering all the facts and I'm too busy to do this.I understand. I myself am actually too busy for this whole discussion, yet here I am. From the style and content of what you write, I take it you are a rocket scientist. If so, your devotion to your dicipline must give you an intimate familiarity with the details of what's involved in launching, say, a cruise missile. Do you feel that this familiarity is indispensible -- or even helpful -- in considering possible ethical problems which might arise around the decision to actually launch such a missile, or the choice of targets?

Dymanic

6th May 2007, 04:44 PM

But in the initial phase, whether that is weeks or months, the public health in developed countries will be able to contain the disease. We do it all the time. You isolate and treat everyone who has had exposure to the patient.Can you offer an example of this having been successful where the disease was one to which there was no pre-existing immunity in the popuation, against which there was no proven vaccine, which was both airborne and fomite-borne, and contagious before onset of symptoms?

People are not infectious until they incubate the disease so you don't have to treat contacts of contacts unless one of those initial contacts becomes a case.That's good, because when you start talking about contacts of contacts, you could be looking at a pretty large number of people. Due to the way influenza is transmitted, just the number of contacts could be nothing to sneeze at (so to speak).

You missed my point. It isn't triage, it's misguided compassion.I'm pretty sure I did get your point. I'm saying that because the situation is analogous to battlefield triage, there is no place for misguided compassion -- but many doctors may not recognize this; hence, I agree with you that they are likely to waste doses.

You exaggerate the role herd immunity plays in determining risk vs benefit in the question of whether or not to vaccinate. While herd immunity is very important in overall disease reduction, you have to have an extraordinarily high risk of adverse outcome such as an allergy to a vaccine component before the risk of vaccinating outweighs the risk of disease.Or an extraordinarily low risk of complications from the disease itself.

If you think herd immunity is a reason to forgo a routine vaccine because the risk of disease becomes small enough that the risk of vaccine now out weighs it, chances are you have an inflated perception of the risk of the vaccine or an inflated perception of how safe herd immunity makes you.Perhaps, but since it was only an analogy anyway, let's say that the situation is roughly as I described, and look at the ethical aspects of choosing a strategy that benefits one's self at the expense (or possible expense) of others. This is essentially what the OP's hypothetical patient wants to do. The question remains whether or not the physician has a moral obligation to support that. My opinion, btw, is that he does not, but neither would I consider it grossly irresponsible.

if there is a shortage of Tamiflu and it is the only protection against a deadly flu strain, you may actually be safer if the public health controls the disease.I agree. The likelihood of contracting the virus increases with the number of infectious people in the community, so giving it to grocery clerks, whatever, might reduce an individual's risk even more than taking the drug himself -- but that seems a little thin. Giving it to power plant operators, garbage collectors, firefighters, etc, definitely makes the individual safer (assuming that the drug actually works).

If a pandemic gets going and there is no treatment, stock up on food and stay home.I agree with this most enthusiastically -- except that I wouldn't wait until a pandemic actually starts to begin stocking up, because the same idea is going to suddenly occur to a whole bunch of people all at the same time; the lines could get pretty long. Part of my concern is that for a great many people "just stay home" is not a particularly viable option -- and if they do, that's going to have consequences of its own.

Ivor the Engineer

6th May 2007, 04:53 PM

You are confusing a prescription to have on hand (which we do all the time) with one for someone who wants to take it now but doesn't need it.

I don't believe I've known any GP's that would give me a prescription for drugs that I might need in the future, simply because I would promise that I would not take them when I felt like it, but only when I thought really needed them.

Perhaps things are different in the US?

Gurdur

6th May 2007, 05:06 PM

.....I'm pretty sure I did get your point. I'm saying that because the situation is analogous to battlefield triage ....
Really good example, but you could have also simply used "highway triage" rather than the more dramatic battle triage; perhaps I am used to a better health system, but here it's standard to have a triage doc just to judge immediate situations and plan proceedings in bad autobahn accidents.

Or NHS triage, drawing on the UK system for example.

Gurdur

6th May 2007, 05:12 PM

If everyone just stays home, then how will we keep supplies of food and water available?
In the case of food, who will drive the supply trucks, and who will stock the shelves?........Let's just hope we can curb an outbreak quickly. There's too many people jammed into cities to have them all stockpiling for a pandemic? Or should I just start anyways?
If this area REALLY interests you, and you like considering the idea, the best idea for you would be to read up on the influenza epidemic of 1918/1921 -- take a look at how many it killed (millions upon millions), and what measures were effective and what weren't effective.

There are a large number of very good books on this specific subject, well worth looking into. The flu then made the black plague look ..... not so bad.

Slimething

6th May 2007, 09:14 PM

From the style and content of what you write, I take it you are a rocket scientist.

Dynamic, you also have missed your guess! I do love flattery, though. How you do go on! :blush:

If so, your devotion to your dicipline must give you an intimate familiarity with the details of what's involved in launching, say, a cruise missile. Do you feel that this familiarity is indispensible -- or even helpful -- in considering possible ethical problems which might arise around the decision to actually launch such a missile, or the choice of targets?

I'm a trace organic analytical chemist. Yes, I do agree that the themes of ethical decision making resonate through different scenarios. In the case of this doctor and patient, the doctor must balance his professional needs (his code of ethics), the patient's needs (a substance s/he perceives as vital for survival), the needs of society (risk of the patient abusing said substance with disastrous results) and the true nature of the substance (is it really as effective as the patient believes?). Too many inputs for me, as a non-medical person, to sift through for an answer.

However, as the thread fills out, more and more factors are becoming better defined so that you and I may be able to weigh in with more informed opinion, guidance and maybe even a proposed course of action.

Thanks, by the way, for mistaking me for a rocket scientist! :)

skeptigirl

7th May 2007, 12:44 AM

I don't believe I've known any GP's that would give me a prescription for drugs that I might need in the future, simply because I would promise that I would not take them when I felt like it, but only when I thought really needed them.

Perhaps things are different in the US?You just haven't needed any I presume.

Here are some examples:

Epi-pen for allergic reactions; asthma drugs; acyclovir or related drug to take at the first symptom of herpes onset; antibiotic to take at the onset of symptoms for recurrent urinary tract infection; migraine medications, and so on.

It is very common to have drugs prescribed for medical needs one is familiar with the symptoms of, and which recur.

skeptigirl

7th May 2007, 01:11 AM

Can you offer an example of this having been successful where the disease was one to which there was no pre-existing immunity in the popuation, against which there was no proven vaccine, which was both airborne and fomite-borne, and contagious before onset of symptoms?SARS

That's good, because when you start talking about contacts of contacts, you could be looking at a pretty large number of people. Due to the way influenza is transmitted, just the number of contacts could be nothing to sneeze at (so to speak). You might be surprised to find out most cases of influenza are spread by droplets, rather than truly airborne. That means short airborne distances and surface contact. Hand washing alone could probably prevent more than half of influenza cases.

I'm pretty sure I did get your point. I'm saying that because the situation is analogous to battlefield triage, there is no place for misguided compassion -- but many doctors may not recognize this; hence, I agree with you that they are likely to waste doses.Evidence based medicine triage of limited Tamiflu doses would recognize the futility of giving the drug to people who had been ill > 48 hours and would therefore triage the doses to the newly infected rather than the most severely ill. Triage does not always mean you attend to the sickest. There are times you are less likely to be able to help some people so you leave them to assist those who you believe can survive.

Perhaps, but since it was only an analogy anyway, let's say that the situation is roughly as I described, and look at the ethical aspects of choosing a strategy that benefits one's self at the expense (or possible expense) of others. This is essentially what the OP's hypothetical patient wants to do. The question remains whether or not the physician has a moral obligation to support that. My opinion, btw, is that he does not, but neither would I consider it grossly irresponsible.Those pesky moral dilemmas.

I agree. The likelihood of contracting the virus increases with the number of infectious people in the community, so giving it to grocery clerks, whatever, might reduce an individual's risk even more than taking the drug himself -- but that seems a little thin. Giving it to power plant operators, garbage collectors, firefighters, etc, definitely makes the individual safer (assuming that the drug actually works).Grocery clerks are not on the priority list. Contacts of cases are highest on the list. Health care workers are next, followed by people performing essential services. After that you give it to the people you expect to suffer the highest mortality rates. There may be disagreement which of the last two is a higher priority.

I agree with this most enthusiastically -- except that I wouldn't wait until a pandemic actually starts to begin stocking up, because the same idea is going to suddenly occur to a whole bunch of people all at the same time; the lines could get pretty long. Part of my concern is that for a great many people "just stay home" is not a particularly viable option -- and if they do, that's going to have consequences of its own.Well around here they promote 3 days of supplies for any major disaster. I believe the Mormons promote a year's supply be stockpiled. We've had a lot of deliberations about how much medical supplies to invest in stockpiling.

I am not afraid of pandemic flu. We know how diseases are transmitted and how to prevent transmission. I would be concerned for children, they are not capable of proper hand washing or other protective measures. I do have a box of proper masks in the house and I keep gloves anyway because of the work I do. If the WHO alert level increases I may decide to keep some Tamiflu and Relenza on hand. But they are quite expensive so I'm keeping a close eye on the H5N1 reports rather than stocking up.

Ivor the Engineer

7th May 2007, 06:19 AM

You just haven't needed any I presume.

Here are some examples:

Epi-pen for allergic reactions; asthma drugs; acyclovir or related drug to take at the first symptom of herpes onset; antibiotic to take at the onset of symptoms for recurrent urinary tract infection; migraine medications, and so on.

It is very common to have drugs prescribed for medical needs one is familiar with the symptoms of, and which recur.

I view the examples you’ve given as somewhat different from the OP. The difference is all the patients in your examples will have gone to a doctor with symptoms at least once before being given a repeat prescription for drugs.

According to the modelling performed in the link I posted earlier, using antivirals in a selfish way (on personal, national or international scales) is not going to work.

Dymanic

7th May 2007, 07:42 AM

kellyb

7th May 2007, 11:55 AM

Is the manufacturer of Tamiflu operating at maximum capacity now? If not, and if they're presently fitting the supply to meet the demand, and will make more based on how high the demand is, then I don't think it would be unethical for a physician to give it to a patient in advance.

But I read (don't remember where...might have been "media science reporting", so it could be wrong) that Tamiflu was only effective when taken before the onset of symptoms. 48 hours after exposure, not symptoms.

If so, that would make the recommendation from the physician on when to take it very, very tricky, and I have no idea what to think from that point on. I'd probably tell my patients to call me for instructions in the event of a pandemic, since the best course of action would depend on factors that won't be known until it happens (such as the degree of transmissibility, the case/fatality ratio, whether or not the virus was becoming milder as the human version of the "dead birds don't fly" phenomenon kicked in, what the WHO and CDC were recommending, etc.)

skeptigirl

7th May 2007, 01:52 PM

I view the examples you’ve given as somewhat different from the OP. The difference is all the patients in your examples will have gone to a doctor with symptoms at least once before being given a repeat prescription for drugs.

According to the modelling performed in the link I posted earlier, using antivirals in a selfish way (on personal, national or international scales) is not going to work.But we also prescribe prophylaxis for influenza for those at risk of serious complications of flu to be taken during flu season. This is no different than that.

skeptigirl

7th May 2007, 02:15 PM

"To date, no cases of SARS have been reported among persons who were exposed to a SARS patient before the onset of the patient's symptoms."
http://www.cdc.gov/ncidod/sars/faq.htm

I'd be surprised to find that all the back-and-forth over the issue of large versus small droplet transmission has been resolved.

"Writing in Emerging Infectious Diseases, Dr. Raymond Tellier of the University of Toronto says there is good evidence that flu viruses often spread via tiny airborne particles, despite a common belief that they travel mainly in large droplets that quickly fall to the ground after a flu patient coughs or sneezes."
http://www.cidrap.umn.edu/cidrap/content/influenza/panflu/news/sep2906airborne.html

Re the droplets, I said MOST not all and droplet spread is the currently accepted means of influenza transmission. There were a couple of studies that airborne transmission was documented. No one, especially me, is saying that never occurs.

I have been an advocate for health care worker safety for infectious disease hazards for over 16 years starting with the demand for needle safety devices instead of signs saying "be careful". There is only one airborne disease NIOSH has an approved respiratory mask protecting workers from and that is TB. I raised that issue specifically with CDC when their interim recommendations for pandemic flu infection control were published. I'm sure I wasn't the only one because they have since undertaken to address the issue of untested recommendations for protective equipment.

BUT, that is for situations of close contact with acutely ill patients some of whom are likely to be shedding large numbers of viruses. I stand by my statement, "You might be surprised to find out most cases of influenza are spread by droplets, rather than truly airborne." The research supports that statement.

Regarding the SARS, I'm not sure I get your point. Nine people got infected in an elevator in Hong Kong, not all of them rode that elevator with the patient, SARS spread in 38 story apartment building in Taiwan possibly through water dripping inside walls (I forget the specifics), health care workers were infected before they realized they had to use disposable gowns as touching the reusable gowns allowed the workers to become contaminated. So people were infected who did not have direct contact with the patients.

But if your issue is, will flu differ, it will. In SARS, one thing making containment possible was the fact no one had mild illness. That was a more critical factor than spread before symptom onset. If pandemic flu were to make 100% of those infected sick enough to be investigated by the public health, then the disease is containable. But when milder cases go undetected, that's when contact tracing begins to fail. That will inevitably occur with pandemic flu. But in the early stages of the pandemic, cases entering the US can be contained. The question will be for how long?

skeptigirl

7th May 2007, 02:19 PM

skepticdoc

7th May 2007, 05:59 PM

I am not Gurdur.

Dymanic

7th May 2007, 06:01 PM

Regarding the SARS, I'm not sure I get your point.I see SARS compared to pandemic influenza all the time, and it's a comparison I don't see as valid, due primarily to the fact that SARS is not contagious before onset of symptoms. Influenza IS contagious before the onset of symptoms, and my point is that this detail renders virtually worthless any strategy for containment through isolation of infected patients.

I imagine the company is at full speed.You'd think so, would't you? Better have a look at this, though:

"The Swiss pharmaceutical company Roche announced today it is scaling back production of oseltamivir (Tamiflu) because of waning demand, and simultaneously questioned whether countries stockpiling the drug are buying enough to protect their citizens in the event of an influenza pandemic."

http://www.cidrap.umn.edu/cidrap/content/influenza/panflu/news/apr2607tamiflu.html

kellyb

7th May 2007, 06:43 PM

How effective is Tamiflu when given after symptom onset?

I think this is what I'm remembering:

http://www.medicalnewstoday.com/medicalnews.php?newsid=66990

New data published in Antimicrobial Agents and Chemotherapy show that the oral antiviral drug Tamiflu (oseltamivir) is effective against two currently circulating strains of H5N1 avian influenza viruses, preventing death if treatment is initiated within twenty four hours of virus exposure[1]. Conclusions drawn from the study data add to the bank of evidence showing Tamiflu is effective against H5N1 avian influenza strains[2], and lend support to the use of Tamiflu during an influenza pandemic.

The study evaluated the administration of 5 mg/kg/day (equivalent to the half of recommended dose of 75 mg/kg in humans) of Tamiflu for five days in ferrets either four hours or twenty-four hours post-infection with either the highly pathogenic A/Vietnam/1023/04 (H5N1) virus strain, or the less pathogenic A/Turkey/15/06 (H5N1) virus strain. When administered within four hours, all ferrets survived inoculation.1 When treatment was delayed until 24 hours after inoculation, treatment with the higher dose of 25 mg/kg/day was required against the Vietnam H5N1 strain and the higher dose of 10 mg/kg/day against the less pathogenic Turkey H5N1 strain.1 This was associated with 100% survival against both strains and markedly reduced the severity of disease, weight loss and fever.1

Slimething

7th May 2007, 07:37 PM

I am not Gurdur.

Thank you for posting that. It has been pointed out to me privately that your demeanor and that of Gurdur's ave dissimilar. So, please accept my apologies. Your not being Gurdur is a very good thing for you.

All I can conclude is that Gurdur has finally lost it. He seems to have convinced himself that your penultimate post was actually his. Sad, really.

skeptigirl

8th May 2007, 01:45 AM

How effective is Tamiflu when given after symptom onset?

I think this is what I'm remembering:

http://www.medicalnewstoday.com/medicalnews.php?newsid=66990

24 hours or less is ideal, using the drug up to 48 hours after symptom onset would be clinically prudent considering the potential hazard the H5N1 flu poses. But in this particular case, having the drug on hand is an issue. Having to make an appointment, go in, get diagnosed, fill a prescription are all potentially going to delay treatment when time is such a critical factor. All the more reason to prescribes it and have your patients keep it at home with guidelines when to take it.

Ivor the Engineer

8th May 2007, 02:04 AM

24 hours or less is ideal, using the drug up to 48 hours after symptom onset would be clinically prudent considering the potential hazard the H5N1 flu poses. But in this particular case, having the drug on hand is an issue. Having to make an appointment, go in, get diagnosed, fill a prescription are all potentially going to delay treatment when time is such a critical factor. All the more reason to prescribes it and have your patients keep it at home with guidelines when to take it.

Let's say that a patient does in fact have flu and takes their pre-purchased Tamiflu at just the right time in the right dose for it to be effective. Do they gain any natural resistance to the virus?

skeptigirl

8th May 2007, 02:09 AM

I see SARS compared to pandemic influenza all the time, and it's a comparison I don't see as valid, due primarily to the fact that SARS is not contagious before onset of symptoms. Influenza IS contagious before the onset of symptoms, and my point is that this detail renders virtually worthless any strategy for containment through isolation of infected patients.There is a reason the two are not exactly comparable, but you are mistaken about the infectiousness prior to onset of symptoms. The issue is mild undetected cases, not infectious prior to onset of symptoms.

Think it through. Why does infectiousness prior to symptoms matter? Because pt A was exposed before symptoms? So what? I detect infected person X. I know the period of communicability. I track down all pt X's contacts during the period of communicability. I also know the organism survives on surfaces for Y period of time. I track down every contact of the surfaces pt X touched or otherwise contaminated during the time the organisms are expected to have survived.

I deal with this all the time. You develop chicken pox. I know the period of communicability is from up to 5 days before symptom onset to 6 days after the rash appears. The incubation period is from 12 to 21 days. The the exposed susceptible contacts could be contagious up to 5 days before symptoms begin. Therefore we exclude them from work from the 7th day after first exposure to the 21st day after the last exposure, or 6 days after the rash appears if they develop the infection. That is the time frame they could potentially be contagious. It isn't rocket science.

There were people infected with SARS who never had direct contact with infectious patients. We found them because every patient with SARS became sick enough to come to the attention of the health care system. What creates the real problem in contact tracing of an outbreak are undetected cases.

One detected case, identify the exposed, isolate them during the time they are potentially going to be infectious. One undetected case and you have all those contacts now becoming potential cases. You have just increased your exposure circle exponentially. If 3 of ten of those cases are now mild and go undetected you can see how you soon lose control.

So you have the right idea, but the wrong factor for making a disease difficult if not impossible to contain. With pandemic flu, the first cases will likely be contained. But eventually the system will be overwhelmed.

I've worked in this field for 17 years. I know what I am talking about.

skeptigirl

8th May 2007, 02:14 AM

Let's say that a patient does in fact have flu and takes their pre-purchased Tamiflu at just the right time in the right dose for it to be effective. Do they gain any natural resistance to the virus?It is highly probably if symptoms begin. If you prevent infection after being exposed then no.

There are cases of failure to develop antibodies in rare cases such as having an infection with chicken pox and mono at the same time has resulted in failure to develop antibodies to chicken pox. So it isn't absolutely guaranteed. But it is likely if you have symptoms and recover you will be immune. Until the virus mutates enough your immune system no longer recognizes it, that is, which could happen with a second wave of H5N1.

You would be better off most likely though should you recover from a case.

Cuddles

8th May 2007, 05:45 AM

Ivor the Engineer

8th May 2007, 06:30 AM

Dymanic

8th May 2007, 08:37 AM

The issue is mild undetected cases, not infectious prior to onset of symptoms.With SARS, we see neither. You say the donkey can't fly because it's too fat, I say it's because it doesn't have wings. Either way, SARS is not a good model for pandemic influenza. Ditto chicken pox.

Think it through.You might be surprised at the amount of time I've spent thinking this through.Why does infectiousness prior to symptoms matter? Because pt A was exposed before symptoms? So what? I detect infected person X. I know the period of communicability. I track down all pt X's contacts during the period of communicability. I also know the organism survives on surfaces for Y period of time. I track down every contact of the surfaces pt X touched or otherwise contaminated during the time the organisms are expected to have survived.Let's take a look at how that might work. A person, apparently healthy, de-planes in some large metropolitan airport after sharing air with some number of other passengers for some number of hours. They walk through the terminal, collect their bags, etc, then take a taxi to a hotel. Later, they maybe go for a walk, and dine in a restaurant. The next day, they suddenly take ill, and wind up in a hospital where they are diagnosed with influenza. Are you going to try to tell me that given any amount of resources you care to propose, there would be a snowball's chance in hell of identifying more than a tiny fraction of all of the people to whom that person was likely to have passed the virus?

With pandemic flu, the first cases will likely be contained.I wish I could be as optimistic. There is a chance that the first clusters will be spotted in time to throw a blanket over them -- if the weather favors helicopter flight and a bunch of other stuff goes exactly right -- but that's not the same thing as what you said earlier:in the early stages of the pandemic, cases entering the US can be contained.If we assume that the first emergence of a pandemic strain occurs somewhere else, then by the time we have cases entering the U.S., the thing will already be spreading exponentially, and we'll have the above scenario taking place numerous times each day. Trying to stop infected people from entering the country will be like standing on the beach to stop the tide.

I've worked in this field for 17 years. I know what I am talking about.I certainly respect that, and if you can straighten me out on this, I'll appreciate it. I've learned a lot from people like yourself. But (respectfully) you haven't worked with pandemic influenza, have you?

Dymanic

8th May 2007, 08:48 AM

Let's say that a patient does in fact have flu and takes their pre-purchased Tamiflu at just the right time in the right dose for it to be effective. Do they gain any natural resistance to the virus?It is highly probably if symptoms begin. If you prevent infection after being exposed then no.
It's an interesting question. If a neuraminidase inhibitor is taken prophylactically, it's conceivable that not so much as a single round of viral reproduction takes place; but even then, it doesn't seem likely. I'd expect to see at least some cells infected, hence at least some exposure to the HA antigen. The question would be whether this exposure was sufficient to stimulate a humoral response.

kellyb

8th May 2007, 08:49 AM

It is highly probably if symptoms begin. If you prevent infection after being exposed then no.

.

According to that link I just posted, they tested that, and even when Tamiflu was given 4 hours after exposure and survived the initial virus challenge, they survived a re-challenge later.

So apparently Tamiflu doesn't, even ideal circumstances, actually prevent infection. It just helps enough to keep you from dying. The actual study (I'd imagine) probably says that the ferrets still got sick, but survived.

ETA:

http://www.medicalnewstoday.com/medicalnews.php?newsid=66990

The research also examined whether Tamiflu treatment affects immune responses for subsequent infections. All ferrets that survived were re-infected 21 days later with the virus, and were found to have developed an immune response that completely protected them from infection.1 Furthermore, no resistance to the drug was detected during the study.1

kellyb

8th May 2007, 09:04 AM

I hope the answer would be a resounding no. The whole point in having a health service, state run or private, it that if you become ill you go to a doctor who works out how to help you. It is not so that doctors can hand out all the drugs they like because it is possible that at some point in the future a few of them might be useful. The point is that treatment goes to those who need it, when they need it, not to those who might need it, before they need it. Handing out Tamiflu on demand would effectively just be saying a big "screw you" to everyone that actually gets ill.

Here's why I disagree:

In the event of a pandemic, Tamiflu will quite possible run out very quickly. So people will be going to doctors who have nothing to give them. And since the manufacturer is scaling down production at this point, buying more now isn't really taking away from people who will need it later. Since we can't expect doctors to personally create their own huge stockpiles, where will the medicine come from?
People personally getting it in advance is the best way for there to be enough of it when/if the time comes.

Honestly, if you were a physician, what would you want to be the case if the worst case scenario were to come true? (and the worst case scenario is 50% mortality). I would rather every one of my patients have it should it be needed. Otherwise, there might not be anything you can do for them.

Ivor the Engineer

8th May 2007, 09:36 AM

Cuddles

8th May 2007, 09:50 AM

Here's why I disagree:

In the event of a pandemic, Tamiflu will quite possible run out very quickly. So people will be going to doctors who have nothing to give them. And since the manufacturer is scaling down production at this point, buying more now isn't really taking away from people who will need it later. Since we can't expect doctors to personally create their own huge stockpiles, where will the medicine come from?
People personally getting it in advance is the best way for there to be enough of it when/if the time comes.

I don't understand your point. A certain amount of Tamiflu is being manufactured. It can either be stored in preperation for an outbreak or it can be given away to people who ask for it. In the former case, all the Tamiflu will be useful. In the latter case, a lot of it probably won't be. The actual amount being made is irrelevant, handing it out or keeping it back has no effect on the amount being made. People personally getting it in advance is the best way to ensure that most people will not take it in the right way at the right time and that those judged to be at high risk or of high importance will not be treated because all their drugs are in someone else's house.

Honestly, if you were a physician, what would you want to be the case if the worst case scenario were to come true? (and the worst case scenario is 50% mortality). I would rather every one of my patients have it should it be needed. Otherwise, there might not be anything you can do for them.

Yes, you would rather every patient has it. But that is not a choice. There is a limited amount available and therefore it needs to be kept for where it is really needed. No plans I have heard about include people who think about stockpiling just in case as high risk or high importance patients. For some reason they tend to focus on things like doctors, police, power companies and things like that. Although I don't have any evidence, I strongly suspect that the people generally judged as being the ones to recieve treatement are not the ones that are likely to be stockpiling, so handing out Tamiflu now is effectively making sure that the people who actually need it won't have it.

Edit: And there is of course the point Ivor makes. People will not wait for a pandemic to take it. If you hand out drugs now, people will take them now. Just look at TB for a perfect example of how not to give out drugs. In the few countries where only a minority had access to proper treatment, TB has emerged as a massively resistant disease and is now set to become just as big a problem globally as it was before we invented medicine. Doing exactly the same for flu, by providing a minority with drugs, which will mostly be taken in the wrong way, just isn't a sensible idea.

kellyb

8th May 2007, 10:29 AM

Cuddles and Ivor...

My point of contention with you both is that the manufacturer is presently scaling back production of Tamiflu, because demand has decreased. If demand were to increase, the supply would increase accordingly. If the governments aren't stockpiling enough, it is them up to individuals to take care of themselves. And the manufacturers will only make what will be bought, either by governments or individuals.

Also, according to the model, if the R0 is much greater than 1.9, all the antivirals in the world are not going to be able to contain the spread.
When you're talking about Tamiflu, it's not about containing the spread so much as it is just keeping the infected from dying. In theory, a vaccine might be able to contain the spread (especially the MedImmune live vaccine, if used in conjunction with large areas of quarantine) but apparently the antiviral doesn't prevent infection, but just does enough to keep you from dying after exposure.

There is a limited amount available and therefore it needs to be kept for where it is really needed
But if people were to buy it now, there would be more. The company will make more to fill the demand. Since they're making less, that means nothing more than less Tamiflu out there for anyone.

Dymanic

8th May 2007, 11:57 AM

When you're talking about Tamiflu, it's not about containing the spread so much as it is just keeping the infected from dying. There is also some emphasis on using it to protect caregivers, emergency personel, etc. Even if you can't control the spread, if you can at least keep enough of these folks on their feet, you'll save lives by minimizing social disruption.

This raises another interesting question: would a person recieving the drug as phrophylaxis -- and who became infected nonetheless, but remained subclinical due to the effectiveness of drug -- be contagious to others? And if (as I suspect) the answer is yes, then wouldn't they potentially pose an even greater risk to others than would a person with no protection at all, since the latter would, in the manner typical of flu victims, cease to be ambulatory in fairly short order?

Ivor the Engineer

8th May 2007, 12:51 PM

Cuddles and Ivor...

My point of contention with you both is that the manufacturer is presently scaling back production of Tamiflu, because demand has decreased. If demand were to increase, the supply would increase accordingly. If the governments aren't stockpiling enough, it is them up to individuals to take care of themselves. And the manufacturers will only make what will be bought, either by governments or individuals.

What leads you to think your government isn't stockpiling enough? If you really believe this to be the case then lobbying politicians to buy more is the responsible thing to do.

When you're talking about Tamiflu, it's not about containing the spread so much as it is just keeping the infected from dying. In theory, a vaccine might be able to contain the spread (especially the MedImmune live vaccine, if used in conjunction with large areas of quarantine) but apparently the antiviral doesn't prevent infection, but just does enough to keep you from dying after exposure.

I don't know enough about how antivirals could be used to contain an outbreak of flu to argue with you.

But if people were to buy it now, there would be more. The company will make more to fill the demand. Since they're making less, that means nothing more than less Tamiflu out there for anyone.

Only if on a massive scale. According to Roche (http://tamiflu-news.newslib.com/story/6871-1263/), they could meet demand for next year even if they stopped production tomorrow. Thus it would require rather more than a few worried patients to get Roche to ramp up production. As I said earlier, it would probably better to write to your local politician to get your government to buy some more if you think the stockpile is insufficient.

kellyb

8th May 2007, 01:21 PM

This raises another interesting question: would a person recieving the drug as phrophylaxis -- and who became infected nonetheless, but remained subclinical due to the effectiveness of drug -- be contagious to others? And if (as I suspect) the answer is yes, then wouldn't they potentially pose an even greater risk to others than would a person with no protection at all, since the latter would, in the manner typical of flu victims, cease to be ambulatory in fairly short order?

I haven't read the ferret study yet (I'll probably go ahead and do that today, since this thread isn't just dying)...but when the drug was given 24 hours after exposure, they had to increase the dosage (compared to when given just 4 hours after exposure) to keep the animals alive. This really makes me think the animals were still very sick, so I'm not sure in the absence of an effective vaccine that hardly anyone would escape with a subclinical case, Tamiflu or not. Unless the virus that emerges is radically different (or is different in humans) than what was seen in that study.
There's also the issue of what was going on with the Chinese poultry workers who apparently had subclinical cases. (Remember them, dymanic? The ones that, if it was a previous infection with a different H5 virus that gave them partial immunity to H5N1...what an amazing coincidence? Don't go back to saying it could have been any old H5 virus...you told me already that I was right and you were wrong ;) ). So that's another complication to wonder about regarding what could happen in humans.
So I think that since with a lot of viruses (even ones we've been dealing with for decades) it's unknown how contagious subclinically infected people are, that will be unknown until it happens. And PCR can't tell you what kind of viral load a shedding person is shedding, so I'd imagine it would take some experience to even figure out what happens in retrospect.

kellyb

8th May 2007, 01:36 PM

What leads you to think your government isn't stockpiling enough?
Well that's what Roche says. Not sure how much that's worth, but still. Either way, they're essentially asking people to buy more.

If you really believe this to be the case then lobbying politicians to buy more is the responsible thing to do.

I might simply be cynical and Jaded, but living in the US, I'm not sure lobbying is terribly effective without capital. But investing in stock in Roche is an interesting idea. :)

Only if on a massive scale. According to Roche, they could meet demand for next year even if they stopped production tomorrow. Thus it would require rather more than a few worried patients to get Roche to ramp up production. As I said earlier, it would probably better to write to your local politician to get your government to buy some more if you think the stockpile is insufficient.

I do see your point, but I just don't see us in a place at this moment where Tamiflu is scarce at all. Doctors are still giving it to exposed people as a preventive who aren't in high risk groups for seasonal influenza. The manufacturer seems to be meeting the various government contract needs and still has an excess to go to whoever wants it elsewhere for seasonal purposes. If they didn't have an excess, they wouldn't be making the decision to make less. They are losing money right now because they're making too much and no one is buying it. So under the present circumstances, I don't think anyone is harmed by individuals purchasing it in preparation for the future.
They're going to give the governments first priority, anyway, since that's where the big money is.

Dymanic

8th May 2007, 01:38 PM

According to the modeling performed in the link I posted earlier, the selfish use of antivirals is going to kill many more people than using them judiciously and the countries in the west using some of their stockpiles in areas of the world which have none/less.
That seems fairly obvious intuitively -- and, ultimately, intuition may be of about as much predictive value as anything in all this. I'd hesitate to place too much confidence in any model; a model is a simplification; if it is useful, this is in part because it is a simplification. One of the inherent simplifications of the study by Colizza et al is that it does not address resistance to antivirals. The model by Lipsitch et al (an examination of which I linked to in my first post to the thread, and which mentions the study by Colizza et al in its first paragraph) has resistance as its primary focus, and therefore ignores other factors. Both of these models allow for quite a bit of tweaking of variables, and like any model, are only as good as the assumptions loaded into them.

It's tempting to think about what would happen if you somehow merged the two models so as to try to look at the outcomes of various containment strategies in the face of various patterns of emergence of resistance -- but at that point, it starts to look more like chaos science than epidemiology; minor adjustments to a single variable might easily send the thing careening off in some direction or other, the end result being perhaps a lively demonstration of programming skills, but not much practical application.

Why this particular flu is likely to be so lethal is that it appears an infected person's immune system over-reacts (cytokine storm), thus young healthy people with strong immune systems are vulnerable.Still somewhat hypothetical, but that is essentially the prevailing wisdom. A minor nitpick is that it isn't a matter of the system over-reacting, exactly; things basically go completely out of whack.

kellyb

8th May 2007, 01:49 PM

Still somewhat hypothetical, but that is essentially the prevailing wisdom. A minor nitpick is that it isn't a matter of the system over-reacting, exactly; things basically go completely out of whack.

Isn't it also based off the 1918 pandemic? Every virologist (well, all four of them) I've ever talked to thought that the conditions of WWI "bred" that virus to be particularly deadly in the young and healthy. (fresh hosts daily, no selective pressure to allow the host to live). So something that emerges today could behave very differently, depending on the circumstances.

skeptigirl

8th May 2007, 02:48 PM

According to that link I just posted, they tested that, and even when Tamiflu was given 4 hours after exposure and survived the initial virus challenge, they survived a re-challenge later.

So apparently Tamiflu doesn't, even ideal circumstances, actually prevent infection. It just helps enough to keep you from dying. The actual study (I'd imagine) probably says that the ferrets still got sick, but survived.

ETA:

http://www.medicalnewstoday.com/medicalnews.php?newsid=66990

Be careful drawing conclusions from very little data and conclusions across different animal models. The study cited provides evidence H5N1 is effective, it doesn't say much about aborting an infection vs treating one in humans and resulting antibody production.

kellyb

8th May 2007, 03:04 PM

Be careful drawing conclusions from very little data and conclusions across different animal models. The study cited provides evidence H5N1 is effective, it doesn't say much about aborting an infection vs treating one in humans and resulting antibody production.

You're right, but ferrets are the very best animal model out there for influenza. Our immune responses are pretty darn close, and as good as it gets since there's really no way to know what will actually happen in humans. So as far as guesses go, this is basically all we have.

ETA: Here's the study. One of the authors (Webster) is the head of the department of influenza viruses for the WHO, so this is pretty important, I think.

http://aac.asm.org/cgi/content/abstract/51/4/1414

skeptigirl

8th May 2007, 03:06 PM

To ask the OP in a different way, would you give Herceptin to a woman just because she asked for it and was worried that she might need it in the future?

I hope the answer would be a resounding no. The whole point in having a health service, state run or private, it that if you become ill you go to a doctor who works out how to help you. It is not so that doctors can hand out all the drugs they like because it is possible that at some point in the future a few of them might be useful. The point is that treatment goes to those who need it, when they need it, not to those who might need it, before they need it. Handing out Tamiflu on demand would effectively just be saying a big "screw you" to everyone that actually gets ill.
This is not an analogous situation.

If you are over 65, allergic to some component of flu vaccine, it is fairly routine to prescribe Tamiflu for prophylaxis during flu season. If you prefer to take the drug at the onset of symptoms instead of all season long, that would be perfectly reasonable.

How does having Tamiflu around in case of a pandemic differ from writing a prescription for an antibiotic for someone to have who wants to put it in a first aid kit for a 2 month wilderness trek? The choice of drug would cover wounds infected with bacteria one might encounter in the wilderness.

The point you are missing here is as a health care provider with prescriptive authority, I still approach patient care as a joint effort. All people are not children who can't manage a decision without a provider to make it. There are many situations where patients keep antibiotics on hand to take at the onset of an infection as long as I, as a provider, determine that person is capable of making the appropriate assessment and decision to use the drug.

I do have that license to prescribe, BTW, so while one doesn't like to argue from authority, in this case, you can take my word for it.

Edited to add a reply to the moral issue. The purpose of requiring a certain level of expertise prescribing certain drugs is a safety issue and has little to do with public health per se. Of course public health issues arise. Treating contagious disease, limiting drug resistant strains from developing and so on. There is no significant evidence having some people keep Tamiflu on hand in case of a pandemic is going to contribute to drug resistance. I already noted the drug is being used now and resistance is a risk from that broad use, not the few prescriptions I might write at this time.

Consider these scenarios, you are a member of an HMO and you inquire and find your HMO is not going to invest in any supply of Tamiflu. You inquire and find your public health department is only going to stockpile a small amount because it represents a big investment.

So is the individual then wrong or amoral to decide they prefer to spend the money and purchase their own?

Remember, this decision gets modified when the circumstances warrant, such as if there weren't currently enough for the public health or HMO to purchase and the prescription took more away from those agencies.

skeptigirl

8th May 2007, 03:11 PM

You're right, but ferrets are the very best animal model out there for influenza. Our immune responses are pretty darn close, and as good as it gets since there's really no way to know what will actually happen in humans. So as far as guesses go, this is basically all we have.If you took Tamiflu 4 hours after an exposure to H5N1, would you then feel safe that you were immune now because of a single ferret study? No.

If you contracted the flu, it was proven to be H5N1 and you took Tamiflu and survived would it be reasonable to assume you would have developed antibodies to at least the currently circulating strain of H5N1 based on all we know about influenza infection? Yes.

skeptigirl

8th May 2007, 04:03 PM

With SARS, we see neither. You say the donkey can't fly because it's too fat, I say it's because it doesn't have wings. Either way, SARS is not a good model for pandemic influenza. Ditto chicken pox.It does matter that you have a mistaken idea about the capability of contact tracing, but the fact SARS is not the same we do agree.

Let's take a look at how that might work. A person, apparently healthy, de-planes in some large metropolitan airport after sharing air with some number of other passengers for some number of hours. They walk through the terminal, collect their bags, etc, then take a taxi to a hotel. Later, they maybe go for a walk, and dine in a restaurant. The next day, they suddenly take ill, and wind up in a hospital where they are diagnosed with influenza. Are you going to try to tell me that given any amount of resources you care to propose, there would be a snowball's chance in hell of identifying more than a tiny fraction of all of the people to whom that person was likely to have passed the virus?This did actually happen with SARS when 9 infected people all got on planes and flew from Hong Kong to 9 different parts of the world. Hospitals and health care providers were essentially put on alert to be looking for anyone who had arrived from Asian countries with SARS cases and who had certain symptoms.

One Dr from Taiwan who had directly cared for SARS patients went with a group tour to Disneyland Japan and returned home after becoming ill. That happened shortly before I went to Japan with my son and his middle school Japanese class.

That same person you describe could have had symptoms and still gone to all the same places and exposed all the people in your scenario. It happened with SARS. And in some cases SARS was so incredibly infectious you could get it simply from using reusable isolation gowns instead of disposable ones. Around 200 health care workers died after contracting SARS from patients. There are few diseases that contagious and that deadly. Lassa Fever is another. There were 29 health care workers who died from Lassa fever one missionary brought back from Africa.

My point is, even with these extremely infectious diseases deadly diseases, in modern countries with good public health infrastructure, containment is quite possible. You don't get the movie version of "Outbreak" in the real world.

That's not to say an influenza pandemic won't eventually overwhelm the health care system. It probably will. The reason is, while we could contain it in all modern countries, the third world doesn't have the resources to do so. Even with money from wealthier countries there is no public health infrastructure in place and the populations are too poorly educated to control influenza. So eventually since you cannot wall third world countries off, it will spread more and more to every country.

I wish I could be as optimistic. There is a chance that the first clusters will be spotted in time to throw a blanket over them -- if the weather favors helicopter flight and a bunch of other stuff goes exactly right -- but that's not the same thing as what you said earlier: [in the early stages of the pandemic, cases entering the US can be contained.]I'm not sure what you mean - "can be" vs "will likely be"? That is consistent. It is possible (can be) and likely will. Or were you referring to something else?

If we assume that the first emergence of a pandemic strain occurs somewhere else, then by the time we have cases entering the U.S., the thing will already be spreading exponentially, and we'll have the above scenario taking place numerous times each day. Trying to stop infected people from entering the country will be like standing on the beach to stop the tide.

I certainly respect that, and if you can straighten me out on this, I'll appreciate it. I've learned a lot from people like yourself. But (respectfully) you haven't worked with pandemic influenza, have you?The WHO is closely monitoring cases in all countries they are occurring in. Every test for the virus whether it is a human case or bird or other animal outbreak is being sent to specific labs for confirmation. The viral strains are frequently analyzed and monitored (with the exception of a little suspicion China isn't 100% forthcoming and Indonesia has held up sending samples because they want assurances they can get low cost vaccine if the strains are used in vaccine development). The bottom line, stopping the virus hasn't happened. Slowing it and very careful monitoring has.

No one knows what the next pandemic of anything will look like. You just have to look at the HIV pandemic to see that. But influenza, because of its deadly potential is one of the most studied and monitored infectious organisms in the world. A 1918 like pandemic could devastate large segments of the world's population. But one thing I have learned from my years in this field, there are widespread diseases now that are devastating large segments of the world's population, and yet we are still here.

skeptigirl

8th May 2007, 04:16 PM

skeptigirl

8th May 2007, 04:24 PM

I don't understand your point. A certain amount of Tamiflu is being manufactured. It can either be stored in preperation for an outbreak or it can be given away to people who ask for it. In the former case, all the Tamiflu will be useful. In the latter case, a lot of it probably won't be. The actual amount being made is irrelevant, handing it out or keeping it back has no effect on the amount being made. People personally getting it in advance is the best way to ensure that most people will not take it in the right way at the right time and that those judged to be at high risk or of high importance will not be treated because all their drugs are in someone else's house.Whose paying for the supplies to be stored? Are they having trouble filling up the stockpiles? Are the stockpiles in place and that's all that will be stored?

Edit: And there is of course the point Ivor makes. People will not wait for a pandemic to take it. If you hand out drugs now, people will take them now. Just look at TB for a perfect example of how not to give out drugs. In the few countries where only a minority had access to proper treatment, TB has emerged as a massively resistant disease and is now set to become just as big a problem globally as it was before we invented medicine. Doing exactly the same for flu, by providing a minority with drugs, which will mostly be taken in the wrong way, just isn't a sensible idea.There are a few analogies here that just don't wash. There is no shortage of TB drugs, there's a shortage of public funding to treat and many populations who for a number of reasons end up only partially treating a disease that is 1) prone to develop resistance, and 2) typically takes a year or more to treat. It is a set up for antibiotic resistance.

Tamiflu is being widely used around the world for any influenza strain. This is a problem with capitalism and antibiotics or antivirals. Drug companies make them to sell, and health care providers are supposed to be conservative with new ones to limit drug resistance. You have a conflict of goals.

skeptigirl

8th May 2007, 04:28 PM

There is also some emphasis on using it to protect caregivers, emergency personel, etc. Even if you can't control the spread, if you can at least keep enough of these folks on their feet, you'll save lives by minimizing social disruption.

This raises another interesting question: would a person recieving the drug as phrophylaxis -- and who became infected nonetheless, but remained subclinical due to the effectiveness of drug -- be contagious to others? And if (as I suspect) the answer is yes, then wouldn't they potentially pose an even greater risk to others than would a person with no protection at all, since the latter would, in the manner typical of flu victims, cease to be ambulatory in fairly short order?
You might be interested in the fact there is currently widespread use of vaccines in poultry for H5N1.

skeptigirl

8th May 2007, 04:30 PM

What leads you to think your government isn't stockpiling enough? If you really believe this to be the case then lobbying politicians to buy more is the responsible thing to do.Start lobbying. I know they aren't stockpiling enough.

skeptigirl

8th May 2007, 04:35 PM

Isn't it also based off the 1918 pandemic? Every virologist (well, all four of them) I've ever talked to thought that the conditions of WWI "bred" that virus to be particularly deadly in the young and healthy. (fresh hosts daily, no selective pressure to allow the host to live). So something that emerges today could behave very differently, depending on the circumstances.
The virus wasn't "bred" (natural selection pressures) to be deadly. But the conditions for spread were related to troop movement and close living quarters for so many soldiers.

Today's jet travel will do just fine as a pandemic amplifier.

The natural selection processes actually eventually breeds non-lethal strains because dead people don't pass on viral genes.

kellyb

8th May 2007, 04:40 PM

The problem is since there was a big hype, and the pandemic didn't come right away, now you have people believing it was all hype. No perceived risk = no public dollars to stock up on Tamiflu.

I can't prove this, but I also get the impression that the decision was made to invest in vaccine technology primarily over Tamiflu. Which honestly does make more sense. To me, at least. If I had to choose between acess to Tamiflu and access to a live H5N1 vaccine, I'd go with the vax. But getting the manufacturing capabilities up to a point where the needed virus could be made quickly is very expensive. But the investment in the cell technology and manufacturing plants has been made.

Dymanic

8th May 2007, 05:22 PM

Isn't it also based off the 1918 pandemic?
Yes, but not on the basis of clinical data (we do have descriptions of symptoms, etc, but there are certain obvious problems with performing lab work on the victims), but statistical data: the famous "W-shaped curve" in age distribution. "Cytokine storm" is the hypothesis many feel best explains that. As for a thorough understanding of cytokine regulation (and, hence, disregulation), we've a very long way to go -- and from there to actually being able to treat cytokine disregulation... there's no guarantee that we'll ever be able to do that. It may be that the best we can hope for is to develop ways to keep things from progressing that far. So far, those who have actually treated H5N1 cases seem to agree that while neither corticosteroids nor antibiotic prophylaxis seem to help, antiviral therapy does (though at higher doses than previously recommended).

Every virologist (well, all four of them) I've ever talked to thought that the conditions of WWI "bred" that virus to be particularly deadly in the young and healthy. (fresh hosts daily, no selective pressure to allow the host to live).When virologists speculate about such things, it carries more weight than when someone else speculates -- but it's still speculation. No genetic recipe for high virulence has been identified. And since virulence is not exclusively a property possessed by a pathogen, but one which emerges out of the complex interaction between pathogen and host, no recipe is likely to be forthcoming; the proof is in the pudding.
So something that emerges today could behave very differently, depending on the circumstances.Absolutely.

There's also the issue of what was going on with the Chinese poultry workers who apparently had subclinical cases. (Remember them, dymanic? The ones that, if it was a previous infection with a different H5 virus that gave them partial immunity to H5N1...what an amazing coincidence? Don't go back to saying it could have been any old H5 virus...you told me already that I was right and you were wrong.You'd think I'd remember that (as seldom as it happens) but I've discussed this with quite a few people in various places, and I have to confess to not being able to recall the specific discussion you're referring to.