Thursday, August 13, 2009

Management of A(H1N1) epidemic: greater clarity needed

*Dr. Mohan Rao, Prof. Rama Baru, Dr. Rajib Dasgupta, Prof. Sanghmitra Acharya, Prof. K.R. Nayar, Prof. Ramila Bisht, and Dr. Ritu Priya of the Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi write: *

As public health workers, we are concerned with the reaction in various quarters to the A(H1N1) (swine flu) epidemic. The hysteria created by the media and the knee-jerk reaction from the Ministry of Health and Family Welfare, are not conducive to rational and well-informed management of the situation.

Swine flu is not more lethal, for instance, than ordinary flu and dengue. There is thus no need for the panic response. It can be treated like any ordinary flu unless there are complications that require hospitalisation. There needs to be greater clarity in the management and treatment of A(H1N1) so that the public is informed regarding the aetiology, treatment and management of swine flu.

Secondary and tertiary levels should be used for confirmation and treatment alone and not for screening, as is being done at present. Screening should be done at the primary level — whether public or private. These have to be given guidelines for screening and testing. The Indian Medical Association will need to play a proactive role in professionally and ethically sensitising its members. Treatment should, at least in the current phase, be limited to designated public hospitals. The government needs to explicitly come out with guidelines regarding the stage of the epidemic at which presumptive cases and not just (laboratory) confirmed cases will be treated with specific antivirals.

Equally, there is no need for the government to open up testing and treatment in the private sector. As public health workers, we know that the private sector is diverse in quality and competence. The situation therefore is ripe for unnecessary — and expensive — testing for swine flu and unnecessary over-diagnosis and treatment. This will not only lead to resistance to the only drugs we have but widespread exploitation of people wrongly diagnosed to have swine flu. The response to this epidemic must be coordinated by institutions such as the National Institute of Communicable Diseases, Indian Council for Medical Research and the National Institute of Virology and not be guided by clinicians alone.

The swine flu epidemic must not be used as an opportunity for quick money making but must be used to strengthen the capacities of the public health infrastructure, including systems for surveillance and monitoring.

Tamiflu & H1N1 flu (Swine flu)

The US Centers for Disease Control and Prevention (CDC) recommends Tamiflu for prevention and treatment of swine flu. Tamiflu is the first neuraminidase inhibitor tablet for the treatment and prevention of influenza A and B. Tamiflu was approved by the US FDA for the treatment of influenza in October 1999 and for influenza prevention in November 2000.

The product, which was developed by Gilead Sciences, a US biopharmaceutical company (that discovers, develops and manufactures therapies for viral diseases and infectious diseases) is commercialized globally by Hoffmann-La Roche, a Swiss global health-care company that operates worldwide.

Notably, Donald Rumsfeld was chairman of the board of directors of Gilead company from 1997 until 2001, when he was appointed U.S. Secretary of Defense but he retained a huge shareholding.

The CDC website states, "CDC recommends the use of oseltamivir or zanamivir for the treatment and/or prevention of infection with these swine influenza viruses."

Researchers conducted a review of numerous studies of of anti-viral medications, which was then published in the prestigious medical journal Lancet on Jan. 19, 2006. As per this review of 51 randomized controlled trials, Tamiflu was useless against the avian flu and many other flus. Contrary to the CDC, their recommendation was not to use Tamiflu.

According to Roche Laboratories, the pharmaceutical company which owns exclusive distribution rights to the drug, Tamiflu has a shelf life of 48 months.

Stock prices of both the companies Roche and Gilead Sciences soared once the drug was recommended by the government as the best treatment. Gilead earns healthy royalties on every pack of Tamiflu.

Indeed what is lacking in the overall discussion about pandemic flu is disagreement, criticism, and skepticism from researchers willing to question and test the data on the efficacy of Tamiflu.