Ethics of Hoarding Tamiflu to Combat Bird Flu

Worries about the spread of the avian flu have led some doctors and others to hoard supplies of Tamiflu, thought to be the best drug available to fight the spread of the disease. Noah Adams speaks with Michael Osterholm, director of the Center for Infectious Disease Research and Policy, about the ethics of hoarding Tamiflu to combat a possible avian influenza pandemic.

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NOAH ADAMS, host:

This is DAY TO DAY. I'm Noah Adams.

Governments around the world are taking steps to avoid an avian flu epidemic. Japanese officials announced today that more than 80,000 chickens would be killed after bird flu was detected at a farm near Tokyo. The Swiss pharmaceutical firm Roche, maker of the anti-flu drug Tamiflu, is reportedly in talks with Chinese officials about jointly producing the drug, considered one of the few that might help control a global epidemic. Last week Roche announced it was temporarily halting shipment of Tamiflu to private-sector customers in the United States. Roche feared Americans might hoard the drug and create shortages in other parts of the world where there would be a more immediate need. I spoke earlier with Michael Osterholm, director of the Center for Infectious Disease Research and Policy and a professor in the School of Public Health at the University of Minnesota.

Tamiflu is a brand name, yes?

Professor MICHAEL OSTERHOLM (University of Minnesota): Yes, it is.

ADAMS: Antiviral drug. How does that compare to a flu shot--a regular flu vaccine?

Prof. OSTERHOLM: The vaccine is actually killed virus material--in other words, the flu virus taken in through a process where it no longer can infect an individual, but when an individual is exposed to it through such as a shot, your body produces antibody. That is what prevents you from basically getting infected and getting ill. Tamiflu, which is an antiviral drug, is actually something that can be used before you do get infected, but most of the time it's used to treat you after you get sick. This is actually a drug that has to be, as we say, on board. You have to be taking it every minute just before you are exposed, whereas a vaccine has a lifetime of protection from most vaccines.

ADAMS: A preventative and then it's a treatment. Now how long is the treatment good for?

Prof. OSTERHOLM: Some of us actually have concerns just how effective Tamiflu will be against H5N1 or the avian influenza strain should it become the next pandemic strain. We know it works well against the current flu viruses that we see every winter, but the way H5N1 or avian flu actually grows inside the human body, it's very different than typical flu viruses. It grows much faster, to much higher levels and infects many more cell types. And there are some laboratory data right now that suggest it may not work all that well unless you're taking it before you're exposed.

ADAMS: And then you have the issue of the scarcity of it. Are you concerned as a health-care professional that there would not be enough to go around among the people who are actually coming down with an avian flu, if that happens?

Prof. OSTERHOLM: We know today that if we basically take all of the manufacturing capacity that Roche has, and if they even sublicense out to other potential manufacturers the ability to produce this drug, in a five-year period we might produce enough drug to protect 7 percent of the world's population should they get flu. We won't have enough drug; we know that. And if a pandemic should arise tomorrow, next week, next year even, it will impact the whole world so that this drug under any conditions will play only a minor role in really having much impact on a pandemic.

ADAMS: Still, why wouldn't you want it? Why wouldn't you try to get it for your family?

Prof. OSTERHOLM: Oh, I wouldn't for a moment suggest that it's not a good idea to try to have this drug. I would be very, very cautious, however, about taking it unless directed by a physician because the other thing we don't want to do is have a lot of people needlessly taking this drug when they think they have influenza and then allowing for resistance to develop in the influenza viruses that are out there. We want to save it for the time we actually know we're having the pandemic of influenza.

ADAMS: That puts a lot of pressure on family physicians who are getting calls and people showing up in the waiting rooms wanting Tamiflu.

Prof. OSTERHOLM: It's a major issue and one that I find many physicians, actually, on either side of the issue of saying, you know, I want it for myself and my family. Then why shouldn't my patients be able to get it? At the same time others saying, `But if we prescribe it for individuals and we're not able to stockpile it for health-care workers or other groups that the government and other organizations deem as the highest priority, then what have we really accomplished? So it is a major concern today in terms of the debate about what to do to get prepared for pandemic influenza.

ADAMS: In this particular situation, should it be a government decision as to who should get supply of Tamiflu and in fact where should that drug go?

Prof. OSTERHOLM: I personally very strongly favor government oversight of the use of this drug, and it can be done, of course, in collaboration with health professionals. And at this point, I have no doubt that the risk group for developing influenza that we have to most protect are health-care workers. If we don't have vaccine and we want health-care workers to be on the front lines taking care of very sick patients and hopefully saving as many as they can, then we have to get this drug to those who will be also most at risk of developing it from being exposed with the patients.

ADAMS: You know, when you look at diseases around the world, things always seem to be out of balance in terms of who gets a drug and who does not get a drug for whatever reason--financial as well as other reasons. Is there a precedent here for Roche to say, `Well, we're not going to send more to the United States because it may be needed elsewhere more intensely?'

Prof. OSTERHOLM: Well, actually the situation with Roche at this time is a bit complicated. They have a number of obligations they have to meet to governments that they have sold drug to already, and at the same time, they were trying to meet those needs while also fulfilling private-sector requests. It's turned out that with all the publicity the last few weeks, those private-sector requests have skyrocketed and they realize that that's eating into their ability to meet the government requests. At the same time, we also know that we're about to experience the flu season in the Northern Hemisphere, where we are going to have regular flu striking nursing homes and hospitals and other very vulnerable patients, and they needed to be able to have some of that drug available for them. So what they're really trying to do is reposition the drug--in other words, they going to keep producing all they can. It's not a matter of making more supply; they're trying to do that. It's just making sure that the people who need it the most get it and that the government contracts are met in terms of stockpiling the drug.

ADAMS: So it--not to be flip about it, but if you have a supply of the drug in your medicine cabinet and shares of stock in Roche, you're in pretty good shape.

Prof. OSTERHOLM: Well, ultimately the drug is going to be very beneficial to those who take it during this time of the year if they should develop influenza. The real billion-dollar question is what impact will it have should we have an outbreak of avian influenza, and there really is a question as to how effective this drug might be. If that were to be the case, a lot of people who may have bought the drug or who had intended to buy the drug won't, if there are questions about its effectiveness. In addition, if you can't make the drug because the limited manufacturing capacity means that no matter how many orders come in you can't fill them, that also raises questions. So right now, obviously the Roche pharmaceutical company is doing well financially, but in the end as to what role Tamiflu may play long term is still a real question.

ADAMS: Michael Osterholm, director of the Center for Infectious Disease Research and Policy, also professor in the School of Public Health at the University of Minnesota. Thank you, sir.

Prof. OSTERHOLM: Thank you.

ADAMS: Just how dangerous is the bird flu? How can you protect yourself and your family? There's plenty of information at our Web site, npr.org.

NPR's DAY TO DAY continues. I'm Noah Adams.

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