Apr 20, 2007 (CIDRAP News) – Faced with the reality that an effective vaccine is not likely to be available for at least the first several months of an influenza pandemic, some corporations are buying antiviral medications for their employees—both to protect them and to improve the chances that the company could keep providing vital products and services through a pandemic.
Few companies have revealed their plans concerning the use of antivirals, but two of them recently described their plans to supply employees with oseltamivir (Tamiflu): the US division of Roche, the company that makes Tamiflu, based in Nutley, N.J., and Public Service Enterprise Group (PSEG), an energy company that serves nearly 2 million electric customers and 1.6 million gas customers in New Jersey.
Tamiflu is a neuraminidase inhibitor that the World Health Organization (WHO) recommends as the treatment of choice for people infected with H5N1 avian influenza; it is regarded as the best hope for treatment if H5N1 evolves into a pandemic strain. The WHO lists the other licensed neuraminidase inhibitor, zanamivir (Relenza), as a second option for treating H5N1.
Roche and PSEG are among the first large companies to supply their employees with Tamiflu, and their experiences may hold lessons for other companies considering such programs.
Employee antiviral programs gain momentum
Antiviral programs for businesses range from modest stockpiles that would cover only certain at-risk employees to more comprehensive plans intended to cover all workers and even their families.
Roche spokesman Terry Hurley told CIDRAP News that 350 corporations have purchased Tamiflu for their employees. Companies don't order the drug directly from Roche; they obtain the medication either from distributors that ship it to a company clinic, from a pharmacy benefits manager (PBM) that mails the medication to employees, or from local pharmacies.
The idea of companies supplying their employees with antiviral medication, however, has generated some controversy. When Roche rolled out a pandemic planning Web site last July to market Tamiflu to companies, some medical and policy experts charged that the company was favoring more lucrative corporate requests over government stockpile orders.
Mike McGuire, vice president of anti-infectives for Roche, said the company waited until its production capacity reached 400 million treatment courses per year before following though with its employee program. The company's US facilities can produce 80 million treatment courses annually, he said. "Once we filled a number of government orders around the world, had enough for seasonal orders, and had enough to fill our other orders, then we decided to fill our own," he said.
The decision to stockpile or supply antiviral medications isn't an easy one for businesses. Medication cost is one factor to consider, said Stuart Weiss, MD, an emergency medicine physician, pediatrician, and disaster planning expert who has worked for government agencies and healthcare organizations. Also, employee antiviral programs should include a strong educational component and medical screening, which also add to program costs, he said.
"Just giving someone a box of pills without the educational component is wrong," said Weiss, who is a founding partner of MedPrep Consulting Group, based in New York City.
Other factors that companies may weigh when considering an employee Tamiflu program include the drug's 5-year shelf life and scientific uncertainty about efficacy and dosing against an emerging pandemic influenza strain. Antiviral-resistant H5N1 strains have been isolated from a few patients in Vietnam and Egypt. The WHO suggested this week that physicians might consider doubling the standard dosage of Tamiflu for H5N1 patients.
Weiss said companies shouldn't substitute an employee antiviral program for a comprehensive pandemic plan. "Just buying antivirals in a vacuum is a waste of time and resources," he said. Plans to protect employees should also involve social distancing, personal protective equipment, and other mitigation strategies.
Representatives from both Roche and PSEG said the decision to supply employees with Tamiflu represents the next step in their pandemic planning. "We need to still be able to produce lifesaving drugs [during a flu pandemic], and we're extremely proactive," McGuire said. The unpredictability of a pandemic drove Roche's decision to have the drug ready for employees ahead of time. "We're not even sure the doctors will be in their offices when the pandemic hits," he said.
Ronald Mack, MD, medical director at PSEG, based in Newark, N.J., said the company takes the threat of a pandemic very seriously. "We have been sensitized to this type of threat by our past experience responding to 9/11, SARS [severe acute respiratory syndrome], anthrax, the Northeast blackout [of August 2003], and the terrorist threats against downtown Newark," he said.
Implementing an employee Tamiflu program for a large organization takes time, Mack said. "We considered that it would be difficult to do for the first time under urgent circumstances, which would produce competition for resources, and elected to act now," he said.
Who receives it?
All Roche employees are eligible to receive Tamiflu, said Ann Peterka, MD, the company's director of employee health services. The company plan is intended both to maintain the company's ability to continue producing essential drugs and to protect employees, she said.
"We provided Tamiflu to all of our employees since everyone will be needed to get the business back to normal once a pandemic wave has subsided," Peterka said. "And since we have a critical role in ensuring that we are able to supply Tamiflu to all of our stakeholders during a pandemic without interruption, it is important to protect our employees from getting infected so we have the best chance of accomplishing this objective."
Alex Nawotka, director of commercial operations at Roche, said covering all employees will help company operations return to normal more quickly after pandemic waves pass. "We felt that all of our employees are important in that effort," he said.
PSEG's Tamiflu program also includes employees' spouses, dependent children, and domestic partners, Mack said. The goals are to further protect employees and decrease their worries about their families during a pandemic, he said. "The sense is that our workers would not appear [for work] unless they felt that their families were secure. We are a very family-oriented company—multigenerational employment is not unusual," he added.
Neither company was willing to reveal how much Tamiflu would be supplied to each employee or family member.
Steps for prescribing
Sources at both PSEG and Roche say the employee Tamiflu program is just one facet of a broader pandemic flu awareness program, and employees are educated before doctors screen and prescribe them the drug. Other elements include hygiene messages on hand washing and cough etiquette.
Roche employees must complete a computerized educational module before they qualify for the Tamiflu program, Peterka said. After they finish the module, they meet with a company doctor who reviews their medical histories, clears them to receive the drug if no contraindications are found, and gives them Tamiflu packaging materials to review. Roche has contracted with a physician network that can do the screenings on- or off-site, she said.
After an employee has completed the educational material and met with a physician, the prescription is sent to a PBM, which mails the employee his or her Tamiflu supply.
At PSEG, employees attend one of several group information sessions, held February through May and led by physicians, Mack said. Employees complete three brief forms—a medical history, a privacy statement, and an education acknowledgement form—and meet individually with a physician. Those who are cleared to receive Tamiflu are given a supply of the drug, along with instructions for taking it.
In June, after employee prescriptions are processed, said Mack, family members will go through a similar process to receive their supplies of Tamiflu.
What triggers taking the drug?
Another issue for employee antiviral programs is what to tell workers about when to take the drug. Using it for treatment means using it only during the illness, but taking it for prevention during a pandemic could mean taking it for many weeks. Roche and PSEG take different approaches on this point.
Roche said its employee Tamiflu program follows World Health Organization guidelines for seasonal flu treatment and prevention (the WHO says that antivirals can be used preventively as well as for treatment). However, Peterka said employees are told to consult a medical practitioner before they take the drug. "We don't want them self-diagnosing," she said.
Mack said for now PSEG intends for employees to use the antiviral medication to treat flu symptoms in the event of a known pandemic but not for prevention. "This may be modified if an actual pandemic evolves," he said.
Both companies said their Tamiflu programs are just one element of ongoing pandemic communication with employees. Mack said PSEG uses seasonal flu as "practice" for a pandemic; for example, the company makes it easy for employees to get their seasonal flu shots by offering them during work at company expense.
Roche and PSEG have installed touchless water faucets and towel dispensers and have posted educational messages on proper handwashing techniques and cough etiquette.
The Tamiflu program isn't a one-shot educational push, Nowatka said. Some of the ongoing efforts at Roche are aimed at teaching employees the difference between seasonal flu, pandemic flu, and the common cold, he said. "We use a variety of venues: e-mail, kiosks, posters, and weekly newsletters," he said.
Apr 19 WHO statement mentioning possible high-dose oseltamivir treatment for H5N1 patients