Is there a role for Tamiflu in personal pandemic planning?

With respect to buying a personal supply of Tamiflu (or other pandemic supplies), I think (1) it's not a bad idea and (2) you should have the opportunity to buy a personal supply without feeling guilty because you've heard specious arguments against it.

But as much as anything, I'm drawing your attention to the "personal Tamiflu supplies" debate because it is a valuable communications lesson. We're seeing way too much misinformation and outright disinformation [Glossary] regarding a possible influenza pandemic. Quite often, the problem comes from medical experts, governments, and others in public policy roles. This debate over Tamiflu is a prime example.

Over the last couple of days, we noted that some people object to the idea of individuals buying a personal supply of the antiviral drug Tamiflu for use during a possible flu pandemic. [Post #1: The list of objections.] [Post #2: Analysis of the objections.]

Looking at this as both a policy issue and a risk communications issue, risk consultants Peter Sandman and Jody Lanard have reviewed 19 of these objections. I gave a large sampling of their comments in Post #2 above. But I suggest you read their discussion in full.

Of the 19 typical objections, Sandman & Lanard think 18 are specious arguments. However, they do accept the premise of the other objection - what they call the scarcity/rationing argument. This says that "society as a whole is better off if the government has all the Tamiflu."

I'm not sure even that argument is valid. In this post, I'll explain why.

Background: Tamiflu and its current supply

A quick background: Tamiflu is an antiviral drug which fights influenza ("flu") viruses. It's effective in treating the regular seasonal influenza. And as of this writing (March 2006), the World Health Organization expects Tamiflu also will be effective on a pandemic H5N1 flu virus. But that's not certain. Right now, Tamiflu supplies are limited. It will take time to manufacture enough for a pandemic, if such occurs. In the interim, some businesses and individuals are buying their own supplies. Some people object to such supplies or stockpiles.

The scarcity/rationing argument

Repeating from the previous post, in case you haven't seen it, the scarcity/rationing argument goes like this: Since there isn't nearly enough Tamiflu if a pandemic started soon, society as a whole is better off if the government has all the Tamiflu and can decide how to ration it. That decision should be left to government, not to individuals. Tamiflu stockpiles should be nationalized.

Sandman & Lanard call this "the most solid argument against personal stockpiling: that Tamiflu is a scarce medical resource, and that in a national crisis Tamiflu can be allocated more wisely by the government than by the free market."

They say if a pandemic occurs and antiviral drugs are still in short supply, governments probably would choose between two rationing strategies for using the drugs:

• Treat the most vulnerable flu victims - those you think are most likely to die if untreated.


• Protect and treat the people we most need to keep healthy in a severe pandemic - those who can help keep society's infrastructure functioning. (This is probably the rationing approach governments would favor.)

Sandman and Lanard add:

...if you are neither especially vulnerable nor especially useful, you're not going to be on anybody's list. If you don't have your own Tamiflu, you probably won't get any. If you do have your own Tamiflu, every capsule in your stockpile is one less capsule available for the government to allocate to someone whose health is a higher priority than yours. Worse yet, you may not get sick, in which case your stockpile may be wasted while someone else dies for lack of it.

[snip]

Of course some doses may also go to waste in the government's stockpile, waiting for the "right" people to get sick - a point that is rarely mentioned.

I'm not sure I disagree with the scarcity/rationing argument 100%. But two considerations, in particular, make me back away from it.

How is Tamiflu different from other scarce medical supplies?

My first concern deals with consistency. For reasons that aren't clear to me, the "scarcity/rationing argument" for a nationalized Tamiflu stockpile singles out Tamiflu. It holds Tamiflu to some different standard than other critical supplies.

Obviously, Tamiflu wouldn't necessarily be the only precious medical commodity during a pandemic. Others may become scarce. It seems to me that if you accept the scarcity/rationing argument, you are also arguing against individuals stockpiling anything of possible life-or-death importance which could be in limited supply during a pandemic. For example, would we say that a person with foresight and financial ability should NOT, for the common good, stockpile insulin syringes or respiratory supplies or a host of other products used to treat different medical conditions?

Is there some significance or distinction in the fact that the government should control the Tamiflu supply but not the syringe supply? "Of course, there's a distinction," someone might say. "Tamiflu is a direct treatment for influenza, while syringes are not. Tamiflu is in short supply, while syringes are not." But insulin is a direct treatment for another life-threatening condition. And, in a pandemic, the supply of syringes may run low if manufacturing & distribution supply chains falter (i.e., supplies are reduced) and/or if there's panic buying of syringes (demand is increased).

During a pandemic, there's no more reason to die from some untreated medical condition than from the pandemic disease itself. Either way, you die. If you can reduce either risk, why shouldn't you?

Is it wrong for someone to buy and stockpile a two-month supply of insulin syringes? Or do we apply the scarcity/rationing argument and conclude that, as with Tamiflu, the government also should control and ration this potentially scarce commodity (and hundreds of others)?

(Side note #1: If for some reason we accept the rationale that a nationalized Tamiflu stockpile is proper because Tamiflu is (a) a treatment directly associated with the flu, (b) a unique tool during a flu pandemic, and (c) in very short supply, then what do we say about ventilators? They would be a treatment directly associated with the flu, of unique value during a pandemic, and in extremely short supply. Should the government stockpile and ration ventilators? Or is it OK if you or I buy one? Don't get distracted by details like [a] ventilators can't prevent the flu, [b] ventilators are very expensive, and [c] you don't know how to use a ventilator, but you can swallow a pill. Those are side issues and are all addressable. The question remains: As a matter of ethics and public policy, is it OK for an individual to buy a ventilator?)

(Side note #2: I think most people have not begun to grasp our manufacturing and distribution vulnerabilities during a pandemic. Many items which are usually plentiful might become scarce. Quickly.)

(Side note #3: This concern isn't limited to medical supplies. Food and water are of life-or-death importance and could be at risk of shortages in a pandemic. What do we say of people who want to stockpile bottled water or water purification supplies and food?)

Getting the medicine QUICKLY, assuming any is left

Second, I don't think society as a whole is better off with a nationalized stockpile if the government can't get the medicine into the hands of sick people fast enough to benefit them.

Assuming Tamiflu is effective, it's only effective if administered promptly. With respect to Tamiflu's existing use for seasonal flu, Roche's Product Information sheet for Tamiflu states: "Treatment should begin within 2 days of onset of symptoms of influenza." And, of course, the sooner the better. The Patient Information sheet for Tamiflu says it's important to begin treatment "as soon as possible from the first appearance of your flu symptoms."

Or as it says on Roche's Tamiflu.com Web site: "You've Got 48 Hours. Learn why it's urgent to contact your doctor at the first signs of flu."

Assume that you contract bird flu and that the onset of symptoms is unmistakable - within a very short time you develop a fever, start coughing, getting body aches, etc.

Your 48-hour countdown clock is running.

You quickly decide you need to see a doctor. At that moment, where will you be? Likely not already in a doctor's office or emergency room lobby. You'll be at your place of employment ... or getting the kids ready for school ... or you'll be waking up feeling bad at 2:00 a.m. If it's business hours, you'll call the doctor's office for an appointment (hopefully, it's not too late to get in today). Otherwise, you might go to a hospital emergency room.

Yes, in normal circumstances, I assume you often could get started on Tamiflu the same day that symptoms begin. But what if a pandemic is underway? What if you've never seen such a crowded doctor's office or ER? Or what if you're instructed not to come to the doctor's office or ER, but to go to a designated bird flu treatment center at the high school gym or county fairgrounds?

The question is: How well would a nationalized stockpile meet that real and unavoidable deadline for beginning Tamiflu treatment?

Some significant people wonder about this.

U.S. Secretary of Health and Human Services, Michael Leavitt, told a gathering in Indiana on March 23, 2006, "We can stockpile a lot of antivirals, but if we can't get pills in the palms of people's hands in 24 to 48 hours, it won't do any good."

And Dr. Michael Osterholm, director of the Center for Infectious Disease Research and Policy, said in a March 22, 2006 newspaper article, "With the H5N1 virus, the virus storm ... is so remarkable in those first 24 hours that if you don't have the drug [Tamiflu] onboard in those first 24 hours, it may only have limited impact."

As a practical matter, I don't know what distribution process would be used for a government stockpile of Tamiflu. But whatever the distribution system, it involves more steps - and more time - than simply going to your medicine cabinet.

Of course, for the broad population in the foreseeable future, the distribution question may be a moot point if you accept the opening premise that governments would use their limited stockpiles to (a) prevent key workers from getting bird flu and/or (b) treat the most vulnerable. Given limited supplies, anyone else who contracts bird flu presumably wouldn't have access to Tamiflu from the government stockpile anyway; so it wouldn't matter how efficient the distribution system was. (Speedy delivery would be important to the vulnerable populations being treated for infection. That, of course, assumes there is any Tamiflu still available if priority is given to protecting key personnel with preventive doses. Remember: Preventive doses are much larger than treatment doses; so the supply is consumed faster.)

Combine medical preparedness and non-medical preparedness

In any case, Tamiflu is just one tool - a pharmaceutical tool - for dealing with any flu pandemic. There are other, non-medical tools and techniques - some as simple as frequent, thorough handwashing. You should use all the tools you can - medical and non-medical.

(Along this line and while we're citing Peter Sandman's expertise, I recommend his October 2005 column "The Flu Pandemic Preparedness Snowball" with sections titled "Focus less on the pharmaceutical fix" and "Focus more on non-medical preparedness." Really good material.)

I personally think one of the best "tools" would be "social distancing" to the point of staying home and not mixing in public. But staying at home for several weeks isn't practical for most people. So put all of the tools to work - from "social distancing" whenever you can to handwashing to covering your coughs to buying Tamiflu (if you think that's advisable and proper).

Whatever tools and techniques you decide to employ - please get busy preparing.