To Tamiflu or Not to Tamiflu?

Several newspapers around Colorado made mention of yesterday’s report from the Trust for America’s Health in which Colorado received a rating of 9 out of 10 on pandemic preparedness.

Good news, right? For those of us in public health preparedness, it is always nice to hear some good news about our efforts. But it really doesn’t tell the whole story, like most evaluations of this sort.

According to this organization, Colorado’s primary shortcoming is in its decision not to stockpile antiviral medications for pandemic flu. While we are glad to hear that they think we have made great strides in the other nine areas, we didn’t get to tell you why Colorado is not buying huge quantities of antivirals.

During a news conference yesterday, the Trust for America’s Health representatives made a really important point. I’m paraphrasing, but the message was, “Antivirals are just one tool in the whole toolbox for pandemic response.”

I wanted to cheer – but I just breathed a sigh of relief. We have felt misunderstood by the Trust folks ever since they started their annual report on preparedness five years ago because their indicators seemed rather arbitrary and superficial. So, it was nice to hear that they agree with us on the antiviral issue, in spite of ranking Colorado as “deficient” in this area.

Why hasn’t Colorado (and six other states) jumped on board with antiviral stockpiling?

You need to know some background to understand the big picture, so here’s the top 10 reasons why Colorado is not stockpiling antiviral medications such as Tamiflu:

10. The federal government only pays 25 percent of the cost of the antiviral stockpile. That means that state governments are expected to come up with nearly $350 million (collectively)!

9. Since we don’t know what a pandemic virus will actually be, we also don’t know what antiviral medications will work best!

8. Since we don’t know what a pandemic virus will actually be, we also don’t know if antiviral medication will be the best approach to preventing the spread of disease. Right now, the research is leaning toward what we call “social distancing” as the most useful control mechanism – also known as a “non-pharmaceutical intervention.” Social distancing can be the simple act of staying home when you are sick – or it can be the more complex process of closing schools and canceling events.

7. There have been reports of serious side effects from Tamiflu, currently the most effective antiviral for bird flu virus that has spread in other parts of the world in recent years.

6. Antiviral medications, just like the medicines you have at home, have a limited shelf life. Right now, Tamiflu is only useful for five years. What happens in five years – do the states cough up another $350 million?

5. States are not allowed to rotate the stock of medicines. That means that the antivirals stay on a shelf in a locked facility until and/or if there is a pandemic. They can’t be used for any other purpose. Colorado had been negotiating with a big health care provider to host the storage site and rotate the stockpile, so the medication would not expire all at once and be thrown away, but the federal government would not permit this arrangement.

4. Disposal of mass quantities of antiviral medications could be a problem. There are ecotoxicologists (that was a new one for me, too) who predict that wild birds will develop drug-resistant strains of influenza if they are exposed to antiviral medication waste by-products in our water sources. And, it is possible that up to 80 percent of the active chemicals in Tamiflu remain in our wastewater, due to the amount that is excreted by the human body and the way that the chemicals breakdown after disposal.

3. As noted in the Trust for America’s Health report, the Strategic National Stockpile has only 6,000 courses of treatment for children (pediatric antiviral suspension). The federal government has not set any target for stockpiling pediatric antivirals even though children and adolescents are known to often be disproportionately affected by contagious respiratory illnesses.[1]

2. Also noted in the TFAH report are three barriers to stockpiling antivirals at the state level: (i) not all states have the fiscal resources to pony up 75 percent of the costs; (ii) antivirals are all states’ priority for pandemic response; and (iii) states have concerns about storage, rotation, and shelf-life extension strategies.[2]

1. And finally, as Dr. Ned Calonge (NOT Colange), the state’s chief medical officer, said to the media yesterday when the report was released, “We're really talking about using precious state resources to pay for a drug of really uncertain benefit that would be used to address an event of uncertain timing and uncertain severity.”

Here are three newspapers with the Associated Press article:
http://www.rockymountainnews.com/news/2007/dec/19/colorado-scores-high-in-report-on-public-health/
http://www.denverpost.com/search/ci_7752620
http://www.gjsentinel.com/search/content/gen/ap/CO_Pandemic_Readiness_Colorado.html

See the full report at http://healthyamericans.org/reports/bioterror07/.

So what do you think?

Did Colorado and the remaining six states make the wrong choice?

To Tamiflu or not to Tamiflu? That is the question for our survey this week.

Endnotes:
[1] Trust for America’s Health, “Ready or Not? Protecting the Public’s Health from Diseases, Disasters, and Bioterrorism,” December 2007, page 23.

[2] Trust for America’s Health, “Ready or Not? Protecting the Public’s Health from Diseases, Disasters, and Bioterrorism,” December 2007, page 26.