Current evidence shows no place for antiviral drug distribution in a flu pandemic

The BMJ and Cochrane Collaboration showed serious generic failings in the system of publishing full trial evidence about oseltamivir for flu.1 We remain concerned, however, that the insights of service providers during the 2009-10 pandemic have not been given the same public consideration.2

Even the selective evidence available in 2009 cannot justify the financial and public health cost of the government maintaining its oseltamivir orthodoxy during the H1N1 outbreak in the face of evidence demonstrating the indefensibility of such a position. Drugs that might be effective in clinical trials can also be inefficient, or fail to deliver the patient benefit predicted by trial results, when subject to the limitations of general service use. Frontline responders in the pandemic witnessed the wanton abandonment of first principles such as isolation, basic control of infection measures, and clinical assessment in favour of stubborn insistence on managing “England as a single epidemiological unit.” The irrational maintenance of the “containment” phase led directly to perverse and damaging interventions and over-reliance on antiviral drugs in mass prophylaxis, especially in schools. Antiviral drug centres became loci for the spread of infection as thousands of symptomatic and sub-clinical cases—flu can be spread by symptom-free patients3 4—and unaffected contacts convened for a “wonder drug,” with serious potential side effects,1 which would now seem to be no more effective in pandemic management than paracetamol.5

Not to underpin current planning for pandemics and any subsequent responses would be irresponsible. Antiviral drug distribution has no place in a pandemic on current evidence of the drugs’ effectiveness for treatment or mass prophylaxis, and with the increased risk of spread of infection from directing populations to distribution centres.