Carl Heneghan and Matthew Thompson on Tamiflu in children: what’s all the fuss?

Carl Heneghan

Carl Heneghan

The last few days has been hectic since the publication of our systematic review in the BMJ on the use of  antivirals in children.  By now, you are probably aware of the findings given the media interest. Basically, our study raised questions about the usefulness of antiviral flu drugs in preventing and treating flu in children, indicating the harmful effects may not be justified by the limited benefits provided. This puts us in direct conflict with the DOH policy of antivirals for all. I think what is important in the present pandemic is to remember how we spent a number of years preventing a similar strategy with the use of antibiotics in sore throat; especially when the published research showed limited benefits in mild disease and the emergence of resistance became a real issue.   We have been slightly overwhelmed by all the media but are trying to keep a cool head. Having just come out of an interview on the Becky Anderson Show on CNN live at 9 O’clock on Wednesday  there are a couple of things I have learnt over the last few days that have been helpful.

One is to keep up-to date with the news on a daily basis. Why? Well when you are live on TV and the interviewer asks you in a forceful way:

“WHO continues to recommend use of antivirals as treatment for people who are severely ill or are at risk of other health complications,”  “isn’t your advice in direct conflict with the WHO? “

Difficult question to answer when you are on live TV and you are about to directly question whether the WHO advice is correct. However, as I said keeping up to date is the trick, because if you read the rest of the guidance it goes on to say:

“However, it also stressed that the antiviral, made by Swiss pharmaceutical giant Roche, should not be taken by those showing just mild flu-like symptoms”

Having knowledge of and being able to reverberate the above statement made the whole interview go much smoother. Over the last few days Matthew and I have also been canvassing a number of GP colleagues to see where they stand on this and reassuringly they are in accordance with the advice in mild disease.

On a lighter note, what is the best way to keep up to date? I find google news and reader effective. You can easily set yourself up email feeds for key words and guidance and alerts on Google reader. Also, believe it or not, I find twitter very useful: I follow about 50 people or organizations – such as the BMJ who give great information and updates on news stories as they emerge: but, because they only have 140 characters you never feel  overwhelmed by the amount of information provided. Finally doing the press briefings with two of you makes it a lot easier; you can bounce ideas off each other, check where you are up to and distribute some of the workload around so you can meet all of the commitments.

Carl Heneghan is clinical lecturer and deputy director of the Centre for Evidence-Based Medicine in the Department of Primary Health Care at the University of Oxford. He is also a general practitioner.

Matthew Thompson

Matthew Thompson

The last few days have been a bit of a whirlwind, with normal work and meetings put on hold for now. Fortunately, I have a quiet day in surgery this week, so managed to gather thoughts and do some real work and see some real patients.

This is certainly the biggest press event I have been involved in, and suspect the same is true for our Department. Left me thinking how often the BMJ gets such international attention.  Overall, it was great to have a paper fast tracked in the BMJ –  the usual weeks or months of waiting to hear about reviews etc was compounded into a couple of weeks, and at times days. What this meant was rapid fire back and forth responding to the journal, editor and proof reader comments – helpfully all fielded by Carl while I managed to drag myself away from my holiday in France to check manuscript versions etc at a cyber cafe.

I thought the paper would generate some press interest, but was honestly surprised that it has been such a big story. I suppose the combination of swine flu, children, government policies, big pharma etc. was too much to ignore, especially on a relatively quiet week in the press.

The question now in my mind, is what to make of the media onslaught that followed? First of all I was amazed by the skills of many of the reporters – they seemed to be able to turn new information (after all we have been working on this paper for a couple of months, they had a few minutes) into coherent questions and statements for live TV. They did this incredibly rapidly. For instance it took the BBC four minutes to post the story online after the embargo time.  Carl and I both did a bunch of live interviews on TV and radio. Years ago, I used to be terrified to put my hand up in the class at school (you know the shaky voice, trembling chest type anxieties); but overtime the nerves for these big occasions have lessened. I think the major issue is being confident in knowing what you are talking about form a knowledge and a methodological aspect

In terms of live TV interviews what I found tricky was looking directly into the camera (which you cannot really see as it is disguised in some black hole), while being blinded by studio lights, while the producer is giving you a countdown in one ear, and all the time trying NOT to look at the screen, with the live pictures on it, which were always curiously situated off to one side. If you do look at the screen to the side then you have the appearance of looking really shifty!

Was the reporting fair? Well mostly it was. Clearly no-one is going to report the umpteen thousand words of carefully crafted systematic review, so very brief take home points were inevitable. A few of the headlines were ever so slightly over the top, i.e. the “pig flu drug bad for children”, and you could clearly see how both the print and TV would try to grab attention with a catchy headline followed by more balanced report.

As the media interest died down (as it inevitably does), I wondered if it had been too over the top.  A day in surgery was a good way to reflect on it all, none of my patients mentioned that they had seen me on the news, which I was kind of glad about. It was nice “just” being a GP for a day again and focussing on day to day clinical problems (interesting no-one with suspected swine flu that day though…).

Should we have done a press release at all, or just let it sneak out there via the on line BMJ and eventually trickle into the news? Well, we believed the research and our conclusions were valid, and that we were addressing a really important clinical problem … why not? Should we have told the UK Department of Health first, or asked for comments from the WHO, or the pharmaceutical manufacturers of the antivirals….. where would you stop? What if they didn’t really like our conclusions, would we have changed anything? Not really. So, if the point of research is to actually inform clinicians, patients, policy makers etc, I think we were right to get this particular research study out there into the world.

Matthew Thompson is a general practitioner in Oxford, and a clinical scientist at the Department of Primary Health Care at the University of Oxford. He trained originally in Glasgow, but has since worked in South Africa and the USA as a GP. He combines GP work, with research mostly into children’s health issues in primary care, as well as teaching evidence based medicine and supervising academic GP fellows

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  • Dr.Nadaraja Bathirunathan

    I am amused by the media hype and fuss about the H1N1 flu pandemic. Two months ago I arrived at the Chennai Airport in India and in my inebriated state wondered for a few seconds whether the immigration section was manned by monkeys.The immigration officers were covered with face masks and soon I realised they were protecting from swine flu. At that time only a single case with mild fever lasting for a day had been reported in that country with a population of over a billion. All sorts of thoughts went through my brain .What was special about these officers?Were they all women? pregnant?
    Outside in the country they were culling pigs. In some places they were driving them off the streets. There was a brisk trade in Tamiflu.
    All this is unwarranted in the present pandemic where the disease is mild in most people. The virus is an antigenically distinct remnant from the classical H1N1 virus but should obviously share a substantial number of antigenic epitopes. Along with the natural innate immunity a sizeable population would have acquired some immunity as a result of infection with the prevalent classical virus. Reasonably healthy individuals with mild disease are best left alone.
    How should we deal with the susceptible population. Patients with chronic kidney diseae, respiratory illness, pregnant women etc.Sure, Tamiflu is not a wonder drug but it damages the virus. Every infection is a tussle between the parasite and the defence mechanisms of the host. Any damage to the parasite can upset the balance in favour of the host. It is important to damage the virus as early as possible before it can multiply and overwhelm the defence mechanisms of the patient.
    This leaves us with a dilemma. How readily can the Doctor identify the patient who needs the antiflu drug? How early can he do it? I can understand the blanket decision to treat every infected individual. However it is wasteful and unnecessary when a very large number of cases have only mild symptoms and recover rapidly and Tamiflu can do very little to help them.

  • dr deepak singla

    hello everyone
    everyone agrees that mild cases of H1NI INF need to be left alone and only sick cases need to be treated but someone need to educate the masses that the window period between mild sickness and severe sickness can be very short esp. if one develops complications like myocarditis,otherwise private doctors are being made to look like villains as ig they donot anything

  • jon hallett

    Does swine flu have any similarities with ‘Spanish’ flu?

    Is it true that Spanish flue was more lethal in the traditionally ‘strongest’ section of the population because of an over-active immune response e.g. gross production of fluids in the lungs?

    Is it true that Spanish flue attacked mildly at first, then more lethally in a second bout?

    Could the latter lethality be ascribed to ‘improved’ immune response to the virus, caused by previous exposure, leading to overactive immune responses second time around?

    Could the swine flu mortality in Mexico be because the virus has been there unnoticed in a mild first phase indistinguishable from seasonal flue, then second time around triggering the damaging immune responses in people previously exposed to the virus?

    Could innoculating people against a flu virus that kills through immune reaction put them at greater risk of developing lethal immunological symptoms when eventually exposed to the virus (because it improves, or supercharges, the immune response in some way)?

    I have noticed that it is frequently stressed that those dying from swine flu in the uk have underlying health problems, indicating in this phase those with a weak immune system are at risk, but if it does turn into something like Spanish flu, then where would be the logic in making the young, old and sick immunologically stronger and therefore similar to the group who suffered the highest fatalities in the flu pandemic after the great war?

  • jon hallett

    flue? what with extra vowels and missing consonants – today I ordered a wagon load of grey PVC pie …

    but the question about a boosted immune response causing more problems than it solves still stands, doesn’t it?