A Tamiflu Rx question for my prescribing colleagues

[Skeptic Ginger]

And anyone else who wants to chime in.

Last week my neighbor's 14 year old was diagnosed with 2009H1N1. The boy's physician told them Tamiflu was being reserved for high risk patients only and the doc did not prescribe the drug for the boy.

I don't see it that way and I wrote him a script.

Two days later, my neighbor thanked me and said she had just read about the 14 yr old girl who died of H1N1 last Sunday after her provider also declined to write an Rx for Tamiflu.

Tests confirm that 14-year-old Benbrook girl died of swine flu

Quote:

...Lindsey, an eighth-grader, had no underlying health problems. She ran track and played clarinet in the school band, he said. ...

Lindsey went home from school Wednesday evening feeling “flushed,” Osborne said. On Thursday morning, she had a fever, and her mother, Tammy Osborne, made her stay home.

By Friday, Lindsey was congested and feeling worse, so her parents took her to her pediatrician’s office, where she tested positive for flu.

However, she did not receive the antiviral medication Tamiflu because the doctors said the CDC guidelines recommend giving it only to people most at risk, he said.

Health officials announced this month that the antiviral medicines should be reserved for people most at risk, including pregnant women, children younger than 5 and those with certain chronic conditions like asthma and heart disease.

After writing the script for my neighbor, I went back to review the CDC guidelines. We all know Tamiflu works best if given in the first 48 hours and preferably the first 24. CDC guidelines say reserve the Rx for the very ill.

Well what does that mean? I say it means a moderately severe case of flu, not just a case severe enough to be hospitalized. How is any provider supposed to predict in the first 24 hours after symptom onset how ill a person is going to become? Yet if you wait longer than 48 hours, the drug is much less effective. In the case of the Texas girl, that would have been Saturday. She died Sunday. It may already have been too late at that point.

I asked myself, what if it were my son? I would give him the Tamiflu, no question. I wonder how many other providers are having a hard time with the CDC guideline saying reserve the Tamiflu for "severe disease" but yet not addressing the issue of just what that actually means?

My neighbors have another son a year or so younger. He had some mild illness in the few days before the brother became ill. It did not present exactly like influenza.

That would be the kid with mild illness I would not prescribe the Tamiflu for. But the kid with sudden onset, extreme fatigue and temp over 101F? I'm sorry but I'm calling that one severe enough to get Tamiflu until the CDC makes it clear what they mean by reserve a drug for the very ill when the drug may be too late to help on day 3.

[JoeTheJuggler]

Not a prescriber, but just one of those others chiming in. . .

Is the CDC concern about prescribing Tamiflu a concern about the supply of the drug or a concern about causing a Tamiflu-resistant strain of the virus to evolve?

I wonder if the answer to that question would clarify the "when to prescribe" question.

It does seem strange that they say to prescribe it early but only in severe cases. My understanding is that early in the infection, no one has a severe illness.

[Skeptic Ginger]

Originally Posted by JoeTheJuggler

Not a prescriber, but just one of those others chiming in. . .

Is the CDC concern about prescribing Tamiflu a concern about the supply of the drug or a concern about causing a Tamiflu-resistant strain of the virus to evolve?
....

Both. And I agree with their philosophy there. I won't, for example, prescribe it for prophylaxis now. We did when the pandemic first started. But now that we've seen more of what's going on, prophy is just not needed.

It's my feeling/belief/conclusion the CDC hasn't been clear enough about the problem of needing to give a drug in the first 48 hours and at the same time trying to reserve it only for the sickest people. It's almost like they are trying to wish that little problem away or that they are in denial.

They've been searching for evidence the drug works after the first 48 hours. They've even suggested it works then if we give larger doses. And there is some evidence it does. But that still leaves us with the problem of identifying a severe case early on. And for that question, the CDC guideline is absolutely frustratingly silent.

I am angry the guideline led to the girl's death. I am glad I wrote the script for my neighbor's child. And I wonder who at the CDC involved in writing that guideline would withhold the Tamiflu from their own loved ones.

[JoeTheJuggler]

On the supply issue, I just did a little googling and I see that while adult doses are in ample supply, there's a shortage of children's doses. That seems like a pretty huge miscalculation. (I thought we knew from early on that younger people seemed to be at greater risk than older folks.)

So, if I understand right, prescribing Tamiflu for a sick child isn't really a problem for fear of creating resistant viruses (only using it prophylactically--I wasn't aware that that was being done at all).

So the question you're posing is really about the supply issue. That's a toughie. I'd hate to hear of even one child dying because he or she wasn't sick enough to get timely life-saving treatment. But if the epidemic really takes off, overusing it now could result in more deaths later.

Seems to me the solution is for the manufacturers to hurry up and increase the supply so that we have enough for those future cases that we don't have to be too stingy with what's available right now for current cases.

[Aepervius]

Well I looked it up in wiki :

Quote:

Resistance mechanism

The genetic sequence for the neuraminidase enzyme is highly conserved across virus strains. This means that there are relatively few variations, and there is also evidence that variations that do occur tend to be less "fit." Thus, mutations that convey resistance to oseltamivir may also tend to cripple the virus by giving it an otherwise less-functional enzyme. The lack of variation in neuraminidase gives two advantages to oseltamivir and zanamivir, the drugs that target that enzyme. First, these drugs work on a broader spectrum of influenza strains. Second, the development of a robust, resistant virus strain appears to be less likely.[9] It is worth noting that the oseltamivir-resistant strains detected by Kiso et al. all appeared within individual children after treatment with oseltamivir – the children did not catch the resistant strains in human-to-human or bird-to-human transmission.

Sure wiki isn't pubmed, but it does sound like resistance to Oseltamivir isn't to be so feared, to my untrained eye it looks like making the virus less active is an advantage for us (the host).

That said, if really as said in wiki Oseltamivir slow the replication of the Virus down, I would indeed expect the biggest effect in the first phase of incubation.

[Skeptic Ginger]

Resistance to all anti-infectives is a problem. A few Tamiflu resistant strains of 2009H1N1 have occurred, none of which have spread yet. But the gene for resistance is widely circulating in seasonal flu strains, and flu readily exchanges genes between strains.

OTOH, the vaccine is beginning to be available. So there is leeway here.

As for the pediatric doses, a 14 yr old of average size takes an adult dose. Unless you weigh 88 pounds or less, you take an adult dose and since some patients are now being given even higher doses, I would not be concerned giving the 75 mg dose to a child as small as 60 pounds if there was no pediatric dose available. A 50 to 88 pound child is supposed to get 60 mg.

We had years to stock up on Tamiflu. We had months to get it distributed locally. There is no excuse for the government to use excessively strict or unclear prescribing guidelines rather than having obtained enough drug for the need.

And there is still Relenza which neither seasonal nor the new flu are resistant to. A teenager could take Relenza. Why are the docs not prescribing it? You break a capsule and inhale it (with a device) so it would not work for young kids. But it is as if the medical community isn't even aware of the Relenza option. And why has the CDC not added it to the guidelines?

I remain upset.

[Professor Yaffle]

In the UK there was a similar debate, but it was slightly different in that they were talking about blanket coverage for all cases, versus giving it only to high risk groups, (as opposed to severe cases as you are talking about).
http://www.guardian.co.uk/world/2009...ne-paracetamol

There was also some stuff about high rates of side effects in children:
http://www.telegraph.co.uk/health/sw...-children.html#

[Skeptic Ginger]

Regarding the side effects: Kids vomit more. Gee, what a surprise.

They might get dehydrated. That is manageable. Though the need to get an IV in an ED has some risks of its own.

And the benefit the researchers used to weigh the risks against was shortening the symptoms by a day. How about the benefit of preventing death?

It amazes me how much bias there is in the medical community that influenza is a benign disease. I have a much different bias.

[Professor Yaffle]

But if the side effects are very common, would blanket prescription lead to more kids ending up in hospital with dehydration compared to a policy of high risk only prescription leading to some severe cases being missed?

[paximperium]

I would prescribe tamiflu to any of the at risk groups. Younger children, chronic illness, elderly, pregnant and maybe their caretakers. I would not have prescribe tamiflu to a healthy 14year old.

[Professor Yaffle]

This article talked a bit more about neuropsychiatric effects in children:

http://www.guardian.co.uk/society/20...fects-children

[Careyp74]

Originally Posted by paximperium

I would prescribe tamiflu to any of the at risk groups. Younger children, chronic illness, elderly, pregnant and maybe their caretakers. I would not have prescribe tamiflu to a healthy 14year old.

So, in regards to the 14 year old neighbor diagnosed with H1N1, would you have?

Can someone answer: Is there a threat of running out of Tamiflu? Would there be less of a possibility if people with H1N1 received the Rx and did not spread the Flu?

[paximperium]

Originally Posted by Careyp74

So, in regards to the 14 year old neighbor diagnosed with H1N1, would you have?

No.

[JoeTheJuggler]

Originally Posted by Careyp74

Can someone answer: Is there a threat of running out of Tamiflu? Would there be less of a possibility if people with H1N1 received the Rx and did not spread the Flu?

Supplies of adult doses, at least in the U.S. are good. Children's doses are in short supply.

As Skeptigirl points out, though, many of these children's cases are kids big enough to take an adult dose.

[JoeTheJuggler]

Originally Posted by skeptigirl

It amazes me how much bias there is in the medical community that influenza is a benign disease. I have a much different bias.

Me too.

I'd go even broader than that and say that people in general have a pretty distorted view of what is most risky and what isn't. I think few people have an awareness of how dangerous driving is, for example. I think, as with the 30,000 or so flu-related deaths that occur every year, the fact that traffic fatalities seldom make the news makes people sort of assume that that level of deaths is acceptable.

ETA: I would've thought the medical community had a better grasp of actual risks than people in general. OTOH, that isn't setting the bar very high.

[BenBurch]

The issue is not so much running out as it is getting a Tamiflu resistant strain.

I do believe that any pharmacist could convert adult doses into children's doses with some effort. The oral dosage form is a capsule and it can be re-dispensed in a smaller dosage in a standard gel cap...

[Skeptic Ginger]

Originally Posted by Professor Yaffle

But if the side effects are very common, would blanket prescription lead to more kids ending up in hospital with dehydration compared to a policy of high risk only prescription leading to some severe cases being missed?

No, and I am not talking about any "blanket prescription". In addition, the CDC guideline says to give Tamiflu to kids 5 and under who have probable flu.

What I was saying about the research is if your criteria for evaluating Tamiflu is a belief all it will do is shorten the clinical course by a day, then you are going to conclude the risk of increased vomiting outweighs the benefit.

If, OTOH, you use the criteria that a small number of cases of flu in otherwise healthy children are going to be fatal, then vomiting is manageable and the benefit of Tamiflu outweighs the risk.

[Skeptic Ginger]

Originally Posted by paximperium

I would prescribe tamiflu to any of the at risk groups. Younger children, chronic illness, elderly, pregnant and maybe their caretakers. I would not have prescribe tamiflu to a healthy 14year old.

And if the 14 yr old in Texas who died was your patient, would you reassess that position?

[Skeptic Ginger]

Originally Posted by Professor Yaffle

This article talked a bit more about neuropsychiatric effects in children:

http://www.guardian.co.uk/society/20...fects-children

I've followed that claim and don't see that the research supports it. It started with people in Japan believing Tamiflu was causing their children to commit suicide. The effect was not seen in any other country. But just as the Wakefield data led to the current anti-vaxer idiocy, people latched on to that hazard as if it were proved.

CONCLUSIONS: No increase in CNS-related and neuropsychiatric events was observed in adults, children, or adolescents with influenza who were prescribed oseltamivir in this study.

CONCLUSION: In this retrospective cohort study, no increase in claims-based neuropsychiatric events was detected in influenza patients who were and were not exposed to oseltamivir.

The available data do not suggest that the incidence of NPAEs in influenza patients receiving oseltamivir is higher than in those who do not, and no mechanism by which oseltamivir or oseltamivir carboxylate could cause or worsen such events could be identified.


There are more studies like these.

[Skeptic Ginger]

Originally Posted by Careyp74

...
Can someone answer: Is there a threat of running out of Tamiflu? Would there be less of a possibility if people with H1N1 received the Rx and did not spread the Flu?

There is not a worldwide shortage of Tamiflu. There are local shortages due to lack of decisions to stockpile the drug and distribution delays.

Apparently there is a shortage of the pediatric formulation (liquid). I have not looked into this at all. 14 yr olds can mostly swallow capsules just fine.

[Skeptic Ginger]

Originally Posted by paximperium

No.

Just out of curiosity, do you have kids and what age group(s) are they in?


And have you made a determination as to how you would identify a serious case of flu vs a mild case? Are you using the requirement of hospitalization as the criteria? What does that say about the most benefit occurring if the drug is given in the first 48 hours? Have you looked at the data regarding the fatalities that have occurred in patients with no identified risk factors?

I ask this as a clinical consult, not as some rant that you should be making the same clinical decision as I am making.

[Skeptic Ginger]

Originally Posted by JoeTheJuggler

....
ETA: I would've thought the medical community had a better grasp of actual risks than people in general. OTOH, that isn't setting the bar very high.

For influenza, the belief it is a benign disease in healthy people is widespread in the medical community.

You'd probably find just as many health care workers afraid of or at least resistant to flu shots as in the general population.

We tend to know our areas of practice well but other areas, not so much.

A medical researcher or provider involved in researching or treating influenza along with the public health officials are much more likely to fear the flu than other medical professionals.

[ExMinister]

It seems to me we should be erring on the side of prescribing more Tamiflu and not less. If there is any danger whatsoever that a patient could die if his/her symptoms are left untreated, then it is wrong to withhold medication that could prevent this. I would think we would be leaning toward over-prescribing, not under-prescribing, when cases like this child in Benbrook exist.

We already know that otherwise healthy children sometimes die from H1N1. So it's rare. So what? If it is your child who dies, will you care how rare it is? Knowing this, and assuming there is enough Tamiflu to go around, shouldn't the way Tamiflu is prescribed this flu season be adjusted accordingly?

If there isn't enough pediatric Tamiflu available, that needs to be remedied quickly, too.

That's my 2 cents.

[Audible Click]

I don't know if this is exactly on topic but today I took my 86 year old husband to his (not mine) doctor for a follow up on some neuro problems he has. I casually asked him if he knows how the H1NI vaccine will be distributed in our area. He replied that he didn't know but that he wasn't getting a shot and neither was his family. I asked if he was an anti-vaxxer and he said "no" and, of course, said that getting the shot was up to us but that we were not in the high risk group. My husband had a heart valve replacement a little over a year ago and while he's in fairly good shape for his age I thought that he was certainly a good candidate for the H1N1 shot. The doctor also said we may have some immunity from, possibly, being exposed to the swine flu in the 1970's. I'm 23 years younger then my husband and may not qualify for the flu shot but shouldn't he have it?

[Skeptic Ginger]

Originally Posted by Audible Click

I don't know if this is exactly on topic but today I took my 86 year old husband to his (not mine) doctor for a follow up on some neuro problems he has. I casually asked him if he knows how the H1NI vaccine will be distributed in our area. He replied that he didn't know but that he wasn't getting a shot and neither was his family. I asked if he was an anti-vaxxer and he said "no" and, of course, said that getting the shot was up to us but that we were not in the high risk group. My husband had a heart valve replacement a little over a year ago and while he's in fairly good shape for his age I thought that he was certainly a good candidate for the H1N1 shot. The doctor also said we may have some immunity from, possibly, being exposed to the swine flu in the 1970's. I'm 23 years younger then my husband and may not qualify for the flu shot but shouldn't he have it?

People over 65 are less likely to get the new flu strain but if they do get it they are just as likely to have serious complications as with any other flu strain. People over 65 are second in line for the new vaccine. I recommend you both get the vaccine when it becomes available to you, probably within the next month. If you get influenza in the meantime, CDC does recommend Tamiflu for your age group. If Tamiflu is not available because of a shortage, ask for Relenza. And if seasonal flu begins circulating, then you get infected, you need Relenza, not Tamiflu since seasonal flu is resistant. Seasonal flu strains are not currently circulating.

I also just checked the CDC weekly report and the % of swine flu circulating that is resistant to Tamiflu remains at 0.6%.

[JoeTheJuggler]

Originally Posted by skeptigirl

For influenza, the belief it is a benign disease in healthy people is widespread in the medical community.

You'd probably find just as many health care workers afraid of or at least resistant to flu shots as in the general population.

My girlfriend is a nurse, and due to conversations with her I learned that only about 1/2 of health care professionals get the flu shot. At her hospital, anyone who refuses the shot has to fill out an affidavit saying that they refuse it against the urging of the hospital. She tells me that distressingly many still refuse it.

Just to avoid getting depressed over this. . . today I went to get my free seasonal flu shot from the large non-profit hospital here. Last year their free immunization program was very successful, so this year they greatly expanded it (many more locations and many more dates). I expected the turnout today to be relatively small.

I was sooo wrong! When I got there, the line was about 100 people long. They had around 15 stations where they actually gave the shot, so I moved through the line and was finished in just over 5 minutes. I asked one of the people if it was that way all day, and the answer was yes, it's been non-stop.

[Audible Click]

Thank you for the info, Skeptigirl.

ETA: We did get our seasonal flu shots in mid-September.

[JoeTheJuggler]

Originally Posted by skeptigirl

Apparently there is a shortage of the pediatric formulation (liquid). I have not looked into this at all. 14 yr olds can mostly swallow capsules just fine.

That's what I've been reading:

Originally Posted by AP

Associate Press
updated 3:12 p.m. CT, Wed., Sept . 23, 2009
ATLANTA - The maker of Tamiflu on Wednesday said there's a shortage of the children's version of the drug — the first-line treatment for swine flu and seasonal flu.

Switzerland-based Roche Holdings sent a notice to doctors and pharmacists about a shortage of the liquid version of Tamiflu for children and how to handle prescriptions in the meantime.

Linky.

[paximperium]

Originally Posted by skeptigirl

And if the 14 yr old in Texas who died was your patient, would you reassess that position?

No. No more than the half dozen healthy patients with H1N1 I intubated this season.

Originally Posted by skeptigirl

Just out of curiosity, do you have kids and what age group(s) are they in?

Not relevant.

Quote:

And have you made a determination as to how you would identify a serious case of flu vs a mild case?

History, physical and vital signs.

Quote:

Are you using the requirement of hospitalization as the criteria?

Mostly; but I would prescribe tamiflu to an influenza patient with abnormal vital signs even if they looked good. Tachycardia and hypoxia would be primary markers I would look for.

Quote:

What does that say about the most benefit occurring if the drug is given in the first 48 hours?

"If you get any worse within 24hours please see your primary doctor or come back here for a recheck."

Quote:

Have you looked at the data regarding the fatalities that have occurred in patients with no identified risk factors?

I've only read a few CDC and County bulletins. The Infectious Disease docs continue to harp on limiting tamiflu prescription unless they meet specific criteria.

[ExMinister]

ETA: In response to Joe, my local pharmacy verified that for me this morning too. They are running low on the pediatric Tamiflu for the youngest kids/infants.

[Skeptic Ginger]

Originally Posted by paximperium

...
Not relevant.

It is relevant. What I was thinking was, would I give or not give Tamiflu to my own child. I could not in good conscience, give it to my child and not someone else's. You know there is a different decision making process there. While we'd all like to think we are following standards because we believe they are correct. There are times when that is not such a clear decision.

Quote:

History, physical and vital signs.
Mostly; but I would prescribe tamiflu to an influenza patient with abnormal vital signs even if they looked good. Tachycardia and hypoxia would be primary markers I would look for.

A fever of 101 or greater is usually accompanied by tachycardia. Can all parents safely assess hypoxia? I've seen nurses who couldn't.

Quote:

"If you get any worse within 24hours please see your primary doctor or come back here for a recheck."

My problem with this is how often I've seen parents who after being sent home are reluctant to return, especially to an ED. There is a psychological barrier to returning to a medical provider after being sent away which has led to the death of more than one child. In addition, many of these kids are being told by their PMDs not to even bring the child in. The parent relates the symptoms over the phone and the provider says no treatment needed.

Is your ED phone triaging these kids? Are they being told to come in or not?

Quote:

I've only read a few CDC and County bulletins. The Infectious Disease docs continue to harp on limiting tamiflu prescription unless they meet specific criteria.

With no discussion of using Relenza?

I'll post the data here in a bit. Quite a few of the fatalities have been in older children and adults with no identified risk factors. From my memory, it's been anywhere from 25 to 50% of the fatalities depending on the study.

[Dymanic]

Originally Posted by Skeptigirl

And have you made a determination as to how you would identify a serious case of flu vs a mild case?

Originally Posted by paximperium

History, physical and vital signs.

The question as Skeptigirl asked it in the OP is the tricky one. A troubling number of the fatalities have been in patients with no previous history or any underlying conditions which would easily identify them as being at particularly high risk, and adopting a wait-and-see approach to sorting them out suffers from the drawback that serious illness typically does not emerge until well after the optimal time for initiating antiviral therapy has passed. Hand the stuff out to every previously healthy young person who presents, and you'll be throwing a lot of doses away on patients who didn't need them; but wait until they get really sick, and you'll be throwing them away anyway (at least, you'll be throwing away a lot of the potential effectiveness of those doses).

I sure don't see any easy solution to this puzzle. It's not even clear to me what would constitute "erring on the side of caution".

[paximperium]

Originally Posted by skeptigirl

It is relevant. What I was thinking was, would I give or not give Tamiflu to my own child. I could not in good conscience, give it to my child and not someone else's. You know there is a different decision making process there. While we'd all like to think we are following standards because we believe they are correct. There are times when that is not such a clear decision.

I agree, but the standards you set yourself as a professional is not absolute and I do not expect it to matter in the case of a loved one. Being a dad, mom or son overwhelms whatever professionalism you have. We are human after all.

Quote:

A fever of 101 or greater is usually accompanied by tachycardia. Can all parents safely assess hypoxia? I've seen nurses who couldn't.

It is about presentation to the doctor, not home self diagnosis. If a young healthy kid's fever improves with tylenol in the ER and their heart rate and pulsox is normal, I consider it a mild flu or too early to consider treatment.

As an ER doc I get the luxury of making sure they see their pediatrian within 24hours after an ER visit by getting our Call-back nurse to help make sure it happens...unless they rapidly improve which is not likely with real influenza.
A pediatrician also gets a similar advantage in calling back or scheduling a recheck the next day if they are worried.

Quote:

My problem with this is how often I've seen parents who after being sent home are reluctant to return, especially to an ED. There is a psychological barrier to returning to a medical provider after being sent away which has led to the death of more than one child. In addition, many of these kids are being told by their PMDs not to even bring the child in. The parent relates the symptoms over the phone and the provider says no treatment needed.

I'm not totally familiar with other systems. We have an Influenza Pandemic Clinic ready to go if or when it really strikes this winter. Until then, most just show up to their pediatrician's office.

Quote:

Is your ED phone triaging these kids? Are they being told to come in or not?

Most are told to come in if they are worried(especially if their fevers do not improve with tylenol/motrin) or they will be scheduled for a pediatricians visit.

Quote:

With no discussion of using Relenza?

Not to my knowledge. I know of it but I do not recall any specific bulletins about it.

[Skeptic Ginger]

From this WHO report on resistance to Tamiflu there is nothing there indicating widening our prescribing to those persons moderately ill is particularly risky. Especially given the fact the new vaccine is beginning to be distributed.

By moderately, I mean a person with a pretty significant case of flu but not a person with a mild case. I remain concerned that "severe" is really subjective at this point. I can't imagine there is any kind of consensus as to where the line on the continuum between moderate and severe actually lies.

Resistance is associated with immunocompromised patients and with prophylaxis.

Quote:

Current conclusions [09-25-09]

These data support several conclusions. Cases of oseltamivir-resistant viruses continue to be sporadic and infrequent, with no evidence that oseltamivir-resistant pandemic H1N1 viruses are circulating within communities or worldwide.

To date, person-to-person transmission of these oseltamivir resistant viruses has not been conclusively demonstrated. In some situations, however, local transmission may have occurred, but without any further onward or ongoing transmission.

Except for immunocompromised patients, those infected with an oseltamivir-resistant pandemic H1N1 virus have experienced typical uncomplicated influenza symptoms. No evidence suggests that oseltamivir-resistant viruses are causing a different or more severe form of illness.

The occurrence of oseltamivir-resistant viruses is expected and is consistent with observations from early clinical trials. As use of antiviral drugs continues to grow, further reports of drug-resistance viruses are certain to occur. WHO and its network of collaborating laboratories are closely monitoring the situation and will issue information and advice on a regular basis as indicated.

[JoeTheJuggler]

Originally Posted by Dymanic

I sure don't see any easy solution to this puzzle. It's not even clear to me what would constitute "erring on the side of caution".

Increase the supply of children's Tamiflu for future cases and use whatever is in the current supply right now. (And Roche says they're doing just that.)

ETA: I don't know if that's an "easy" solution, but it's certainly simple.

Also, as someone pointed out (and I've confirmed on the googlewebs), it's possible for pharmacists to grind up adult doses (or simply open capsules I guess) and make pediatric doses. Since there's an abundant supply of adult doses, there really is no shortage problem at all. (Also, as Skeptigirl points out, many of these "kids" are big enough to take adult doses--or at least can swallow capsules.)

It sounds like the resistance issue isn't one that these cases would worsen (unlike the prophylactic use of Tamiflu), so it sounds to me like the CDC really should change its recommendations.

[JoeTheJuggler]

Here's my Conspiracy Theory on the issue. (Gee, I've never started one before.)

The government is trying to protect the supply of Tamiflu because it either has knowledge of terrorist plans to use a biological weapon or because the Gummint itself is plotting to use biologicals.



ETA: I'd bet money that someone will point out to me that my CT has already been put forth seriously.

[Skeptic Ginger]

I asked a friend of mine what they were doing at her ED and she said the patients coming in with probable flu were mostly getting Tamiflu. So you go to an ED and it is assumed you are sicker than if you go to your PMD.

But if Dr I's ED is more conservative with the Tamiflu, we are back to individual provider judgment about what constitutes a severe case.

Leaving that up to provider judgment is fine in most cases. What I am thinking, however, is there is so much bias in the medical community about influenza that it is biasing that usually more neutral judgment.

This is speculation, of course, but think about the OP example. A 2 yr old with a temp of 104 is pretty common. And you wouldn't get that excited about it barring other factors. You would advise the family to take measures to lower the child's temp.

But a 14 yr old with a temp of 104 is seriously ill as is an adult with a temp of 104. Young kids' fever control mechanisms are not as well developed. So the fever is the result of the child's body's immaturity. The 14 yr old's fever is the result of the severity of the infection.

Why didn't the pediatrician's office recognize that when the family called them back? One possibility is the staff were in the mindset flu is mild. That creates a kind of tunnel vision and you don't see outside the tunnel.

[GreNME]

Originally Posted by paximperium

I'm not totally familiar with other systems. We have an Influenza Pandemic Clinic ready to go if or when it really strikes this winter. Until then, most just show up to their pediatrician's office.

They have these in TX already, and I believe some other places. Some hospitals have set up large tents outside the hospital on the grounds to take care of the people coming in (mostly kids). You know what? It's working.

That's what gets me most about all of this hype: here on this website we consistently point out the ratio of hits and misses to people regarding cold readers, and how those who fall for it are counting the hits and disregarding the misses. Yet with the H1N1, it seems the hype is more interested in highlighting the deaths and ignoring or glossing over the vast majority (not just 60-80%) who are dealing with being sick for a few days to a week, then none the worse for wear thanks to doctor recommendations of hydration, no activity, and plenty of rest. I've heard exactly one report (on NPR) from a reporter whose daughter caught it, was under bedrest for 3-4 days, and then recounted her time (mainly boredom) to her dad for the report itself. Everyone else is "OMG SOMEONE DIED!!!1!ELEVENTYONE!!"

One of the little-known pieces of information: the flu is affecting kids 25 and under due to a lack of resistance that people in their 30s and 40s have, and people older than that have already lived through from a strain in the middle of last century that bears a remarkable resemblance.

Consider me one of those who isn't questioning your professional integrity, paximperium.

[fls]

Originally Posted by skeptigirl

What I am thinking, however, is there is so much bias in the medical community about influenza that it is biasing that usually more neutral judgment.

Perhaps they are better inoculated against the availability bias?

Linda

[Skeptic Ginger]

Originally Posted by fls

Perhaps they are better inoculated against the availability bias?

Linda

I'm not quite clear which side you are referring to by "they".

Roche has been pumping out Tamiflu since 2005 and lots of people have taken the opportunity to stockpile it. In addition, expired stock is still good and in the US we can use it by order of the CDC.

Drugmaker considers Tamiflu supplies 'reasonable'; April 29, 2009

Quote:

Global supplies of Tamiflu are "reasonable" because a generally mild flu season in the Northern Hemisphere left stockpiles largely untapped, said Terry Hurley, a spokesman for the drug's maker, Roche.

The company already was working to boost its global production capacity for Tamiflu, Hurley said. Within 12 months, he added, it will be able to make enough of the drug to treat 400 million people a year.

Drug combination 'could double Tamiflu supplies'; Source: Nature; 2 November 2005 Probenecid prevents urinary excretion of Tamiflu and can be used to extend supplies in an emergency.

‘No shortfall in Tamiflu supplies’ Aug 09

Quote:

Capacity is not a constraint and we can supply 20 million doses in 10 days, and, if required, go up to 100 million capsules (needed to treat 10 million patients).”

Two months ago, the government asked companies making Oseltamivir to stockpile adequate raw material (mainly shikimic acid) in case of emergency.

Ample Tamiflu supply exists for 2008-2009 season.APRIL 27, 2009; Cipla Can Supply Generic Tamiflu Chugai/Roche to up Tamiflu supplies to Japan threefold; 8 Sept. 09

Quote:

Chugai Pharmaceutical has revealed that it plans to increase the supply to March 2010 of the anti-influenza drug Tamiflu Capsule 75 and Tamiflu Dry Syrup 3% (oseltamivir phosphate) imported from its Swiss parent company Roche, for production and marketing in Japan.

The question I am bringing up here is not about giving Tamiflu to every kid with a runny nose. My issue is how we are defining a case severe enough to warrant Tamiflu.