Public weighs in on pandemic antiviral distribution

May 18, 2012 (CIDRAP News) – The Institute of Medicine (IOM) yesterday shared findings of three public opinion panels on antiviral distribution during a flu pandemic, including a nod for establishing diverse alternative strategies and support for Web and cell-phone information.

The exercises were conducted by the IOM's preparedness forum based on a request from the US Centers for Disease Control and Prevention (CDC). Though CDC officials haven't finalized any alternative distribution strategies, the exercises also provided a glimpse of some options they're considering.

Panel discussions took place in February and March in three locations designed to reflect diverse parts of the country and different population groups.

A session in Fort Benton, Mont., included residents from rural areas, including some from two local Hutterite communities. The one in Chattanooga, Tenn., featured a wide range of ages and reflected the city's African American demographic profile. The workshop in Los Angeles included both blacks and Hispanics and included a number of uninsured people.

All together, the 4-hour workshops involved 232 members of the public, who were given a $50 stipend for their participation.

During a severe flu pandemic, health officials predict that about 30% of the population would get sick over 12 to 18 months, which could overwhelm the usual medication-prescribing systems and slow access to medications that need to be taken within 48 hours to maximize their benefit.

The IOM asked participants to consider three alternate distribution methods:

  • Nurse triage hotlines in which nurses assess callers' symptoms and transmit a prescription, if needed, to the patient's pharmacy
  • Antiviral pick-up and delivery by community contacts geared toward people who have been prescribed antivirals
  • Pharmacists prescribing antivirals under collaborative practice agreements

The CDC also asked the IOM to collect feedback from the public on communication issues surrounding pandemic flu and its treatment. The feedback focused on use of a Web-based tool to help people decide when to seek medical care and a text message tool to provide additional follow-up information to people who have been prescribed antivirals.

At the start of each workshop, an expert gave a presentation on pandemic influenza, which helped frame the dissuasion points. Then the participants divided into small groups, in which they were asked specific questions about the alternate antiviral distribution options under two severe pandemic scenarios: when there are long delays for seeing healthcare providers and when there aren't enough antivirals for everyone who needs them.

The IOM organizers asked the participants about the goals and value that policymakers should consider when designing alternate antiviral dispensing systems, and the questions also touched on allocation prioritization, fairness, transparency, preparedness, and prevention.

At the end of those discussions, the groups reported their key points to the larger group. Participants took opinion surveys at the start and end of the workshop.

When IOM organizers looked at the feedback from all three workshops, they found few regional differences, along with widespread support for the notion that health officials should develop alternate strategies to ease access to antivirals during a severe pandemic. Though they voiced broad acceptance for all three of the strategies, they told the leaders no single strategy could satisfy all needs.

During the small-group conversations, leaders learned, for example, that some participants worried that nurse triage lines could be overwhelmed and that the lack of face-to-face interaction might make flu and other conditions difficult to diagnose. Participants expressed confidence in specially trained nurses and in pharmacists.

Concerning pick-up and delivery method, some expressed concern over risks to people delivering the medications to the sick, reliability of those handling the delivery, and some people not having contacts willing to help out.

For the pharmacist prescriber method, participants liked the face-to-face aspect and said they were already familiar with pharmacists doing other medical tasks, such as administering flu vaccines. Possible disadvantages included potential contact between sick and well people, risk of exposure to pharmacists, and the possibility that antiviral delivery could overwhelm the stores.

Overall, the participants responded favorably to the Web tool and the text messaging system. They expressed concerns that not all people would have Internet access or cell phones and said the most useful information on a Web portal would relate to symptoms, treatment options, when to see a health provider, how to obtain antivirals, and what to expect during antiviral treatment.

During discussions about possible antiviral shortages, participants strongly supported directing scarce resources to those in greatest need and to those who would most benefit, according to the report. They saw mostly downsides for "first come, first served" and lottery-allocation methods, except, for example, distributing antivirals when there are not enough to cover even high-risk groups.

The groups had mixed reactions when asked if providers should have some leeway in making antiviral allocation decisions.

At several points during the workshops, participants aired their own ideas for antiviral distribution, including using pharmacy drive-throughs to help minimize the spread of disease. Some at the rural Montana session said they would trust veterinarians to expand prescribing capacity, and some from the Los Angeles session advised health officials to recruit celebrities to appear in public service announcements about pandemic flu.

Some of the participants had additional comments that weren't directly related to the strategies. For example, some participants at the rural Montana session wondered if federal officials could ease access to antivirals during a pandemic by making them available for over-the-counter sale.

Some of the participants at the Los Angeles session voiced a general mistrust about the safety of the drugs and whether minority groups would be used to test antivirals without benefiting from their widespread use in a pandemic.

In all three locations, participants said pandemic planning should be robust enough to ensure that antiviral scarcity will never be a problem.

The IOM organizers wrote that although the sessions weren't meant to come to a consensus or reflect wider populations, the workshop feedback raises several concerns, including possible misperceptions that the CDC can expect to encounter as it develops alternate antiviral strategies.

The agency praised the quality of the information that the organizers learned and the increase in participant knowledge about pandemic issues and the antiviral strategies. "These types of forums offer reciprocal benefits to participants and policy makers and have a great potential to positively impact the development of public health policy," the authors wrote.

See also:

May 17 IOM preparedness forum summary on antiviral public engagement sessions

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