Physician Calls for Guidelines on Tamiflu Stockpiling

Allan Brett is a professor at the University of South Carolina and director of the General Internal Medicine division. He co-wrote a Perspective article in the Dec. 22, 2005 issue of the New England Journal of Medicine addressing the issue of how physicians should handle patient requests for personal stockpiles of Tamiflu.

You express concern in your piece that patients who received Tamiflu on demand could use it for other illnesses. Do you believe this is because they would be incorrectly diagnosing themselves as having avian flu, or would they use it for other purposes?

I wasn’t trying to say that most people would. That was listed as one of the factors that, taken together, converge in that direction. It would be all kinds of things.

Understandably, according to human nature, perhaps some people would use it for any sort of viral respiratory infection they had. Many others would keep it under lock, but as reports about avian flu increased fear, there is a fairly high probability that at the hint of an epidemic they might take it at the wrong time.

But I want to keep making the point that my whole article is a collection of things.

Should we be concerned about stockpiling leading to Tamiflu resistance?

It’s really unclear. It’s another thing that has to be weighed. I think that inappropriate use of the drug might enhance the chance of resistance. I think it’s a factor, but it’s not clear how big of a factor.

It’s another issue to be weighed in trying to analyze when it’s appropriate for individuals to stockpile, but it’s not the overriding one.

Are you concerned that stockpiling Tamiflu against an avian flu epidemic could decrease effective treatment of seasonal influenza?

It is yet one other factor that one can put on a list. Is it the single over-riding one? No.

Tamiflu is not a panacea for human influenza. It shortens the average duration by about a day, but it doesn’t obliterate it.

From a public health perspective, couldn’t individual supplies of Tamiflu prevent a flu outbreak from spreading by keeping those infected out of medical facilities, as presented by Dr. Anne Moscona in a NEJM perspective article concurrent with yours?

If experts in controlling an epidemic, which I’m not, end up believing the benefit of having a certain drug at home would outweigh the harm of it.

But is has to come down to individual physicians. What I was writing about was willly-nilly, ad hoc requests. That would be okay, what you are describing, if it was well organized with public health officials and physicians working together.

What made me write this was that in September and October physicians started to get these phone calls, or maybe requests tacked on at the end of a visit, and there was no guidance on how to handle it. No directives physicians could use to make these judgments.

What lessons from the 2001 anthrax attacks and subsequent paranoia can be used to deal with this situation?

The lessons from these things collectively -- I think they show reasonable and sensible judgments have to be made by people with public health authority. Where that authority lies is something for people to talk about.

In an instance where individual physicians are caught between individual patients asking for something and a larger public health issue, it’s unfair to leave physicians floundering around on their own. Something above physicians needs to provide organized guidance. It didn’t happen for anthrax and it hasn’t happened with this until now.

In South Carolina public health officials sent an advisory saying no personal stockpiling. But when I was writing this paper in early November, I really couldn’t find anybody. There were many discussions about avian flu, but there hadn’t been any definite statements telling physicians how to deal with avian flu.