Pandemic debate now steered to allotting antivirals

During an influenza pandemic, antiviral drugs will be in short supply, and a national discussion is needed to determine how these medications will be doled out to the population, particularly for prophylaxis care, says a recent Institute of Medicine report.

"We know [antivirals] have a role in treatment, but what does society feel about who should get the drugs for prevention?" asked Andrew T. Pavia, MD, a member of the committee convened by the IOM to create the document, released April 25. "Should it be the elderly? Should it be the children? Should it be the people who we depend on for our safety?"

Much of the debate over how a vaccine for a pandemic influenza virus strain would be used already has occurred. But, members of the IOM's Prophylactic Use of Antiviral Medications During an Influenza Pandemic committee say a similar conversation regarding antivirals is crucial. In the early days of the predicted pandemic, for instance, these medications may be the only tools available to help control the illness' spread. The pandemic vaccine may take months to start rolling out. During that time, health care workers and emergency personnel should be given first priority for these drugs, but who else should get them?

"Given that scarcity is almost a certainty, and this is not a society that knows much about scarcity, we need a lot of public buy-in," said June E. Osborn, MD, committee chair.

Many questions can't be nailed down beforehand. For example, it's unknown which influenza strain would be the pandemic trigger. Other questions include how effective the antivirals will be and how the virus will hit the elderly or the young. What mix of treatment and prophylaxis will protect the greatest number of people? How rapidly will the virus develop resistance? What are the best strategies to avoid that?

"It's very difficult to come down with hard and fast recommendations, because there's so much uncertainty as to how it's going to play out," said Patricia Quinlisk, MD, MPH, a panel member and state epidemiologist with the Iowa Dept. of Public Health.

But committee members hope that state and federal public health officials will use this report as a jumping-off point to tackle the questions that can be answered in advance. These include defining the goals of pandemic antiviral use that balance both ethical concerns and fiscal realities.

"What are the goals of an antiviral program going to be? Provide prophylaxis to the vast majority of the population? If so, how are you going to [do] that? Where are the resources going to come from?" said Dr. Pavia, who is also professor of pediatrics and chief of pediatric infectious disease at the University of Utah School of Medicine in Salt Lake City. "The resources that are being put into public health in general and pandemic preparedness are pretty limited."

Also, the role of stockpiles accumulated by the private sector needs to be determined. The committee is calling for memorandums of understanding and various other agreements between private and public entities to determine how best to use this resource. The federal government's Shelf Life Extension Program, which tests the efficacy of those drugs that are past their expiration dates but might be needed in a pandemic, should be expanded to cover antivirals held by the private sector.

Experts responded that this report was a good first step to help physicians deal with the ethical and logistical issues that may come with antiviral distribution in a pandemic.

"The idea of creating some sort of national ethical framework is really good," said Charles W. Mackett III, MD, executive vice chair of the Dept. of Family Medicine at the University of Pittsburgh Medical Center. He is also chair of his institution's pandemic influenza task force, which has held discussions with local community members about the allocation of its antiviral stockpile.

Health and Human Services issued its pandemic flu plan in November 2005, which included limited guidance on antiviral use. A plan specific to antivirals is under development. The American Medical Association is a consulting organization.