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In June 2009, the World Health Organisation (WHO) announced a pandemic, caused by the influenza A (H1N1) virus commonly known as 'swine-flu' in UK. The symptoms of influenza infection (the swine-flu) are quite similar to that of a normal seasonal influenza namely fever, cold, cough, sore throat, chills, muscle and joint pains, loss of appetite and fatigue. The duration of illness is estimated to be between seven to ten days. Like other seasonal influenza viruses these H1N1 viruses cause severe illness in minority of people with secondary complications. Antiviral drugs are used to treat influenza, two classes of antiviral drugs are available one is adamantine inhibitors (Amantadine and Rimantadine) and the other one is neuraminidase inhibitors (Oseltamivir and Zanamivir).(1*) Laboratory testing showed that the H1N1 virus was resistant to adamantine inhibitors and may be susceptible to neuraminidase inhibitors.(2*) Anti-viral drugs Oseltamavir (Tamiflu) and Zanamir (Relenza) are being used throughout the UK to treat swine-flu. Tamiflu is preferred over Relenza as it comes in the form of oral tablets and can be swallowed easily where as Relenza is an inhalation powder. Relenza is found to be safe in the treatment of influenza in pregnant women.
Oseltamivir phosphate is available in the market in the brand name of Tamiflu. Tamiflu (Oseltamivir phosphate) is an antiviral drug belonging to the class called neuraminidase inhibitors which acts by killing or inhibiting the growth of virus in adults and children over one year who have been symptomatic with influenza infection (the flu). In order for the flu virus to cause a disease it has to make copies of itself inside human cells, these cells are then released from the cell to spread the infection to other cells. The neuraminidase inhibitors prevent the release of virus from cells and thus limits the infectious cycle. These anti-viral drugs can also be used as a prophylaxis of influenza although it is not a substitute to the influenza vaccine (1). Tamiflu is available in the form of capsules in 30mg, 45mg and 70mg strengths and is also available as an oral solution containing 12mg/ml of the active drug. The dosage is specifically adjusted depending on if it is for treatment or for prophylaxis. In children over one year the dosage is calculated depending on body weight. After the drug is taken orally more than 90% of the drug is metabolized in the liver into active form and is excreted through the kidney (2).
The influenza virus was first identified in Mexico in March 2009 since then it became pandemic (spread throughout the globe) by June 2009.(3*) There were three flu pandemics in the twentieth century in the years 1918, 1957 and 1968 which took lives of millions of people around the globe.(3) The recent pandemic caused by novel influenza A (H1N1) swine virus which is spreading globally has undergone an evolutionary reassortment. These new strains of viral sequences are widely different from the past few year sequences it is a mixture of avian, porcine and human influenza RNA. (4) According to WHO UK is one of the countries which is sufficiently prepared for the flu pandemic it has stockpiled up to 50 million doses which is enough to treat 80% of the population.(5).The NHS is taking all necessary measures to make sure the patients at higher risk gets the treatment at the earliest onset of symptoms. High risk groups include people with chronic lung, heart, kidney, liver and neurological disease, immunosuppressant and diabetes mellitus. Also at risk are asthmatic, pregnant women, older people and young children under five. Currently people being confirmed to be suffering from swine-flu are being offered anti-viral drugs either by their GP or the national pandemic flu services(6). British Government has spent approximately £100 million to stockpile Tamiflu, is this money spent appropriately or would it have been better spent on other health initiatives is the question arising here.(ref)
NHS finances have been in a steady state for a while but the situation is becoming more challenging now because the emphasis has been on improving quality, safety and clinical outcome rather than reducing costs. The health secretary is responsible for funding and setting up priorities for NHS. British Government has allocated a funding of £ 164 billion over 2009-10 years which means approximately £1612 per person and the main aim of NHS priority framework for 2009-10 is to provide high quality care to all. One of the NHS top five priorities is to be prepared to respond in case of emergencies like outbreak of pandemic influenza(7). Hence when the swine-flu pandemic aroused the health board acted efficiently and stocked sufficient quantity of Tamiflu for the British population. According to the Daily mail news paper Britain had the third highest number of confirmed swine-flu cases behind Mexico where the outbreak began (8). WHO raised the pandemic alert around the world and advised the health care providers to be prepared to treat patients contracted by swine-flu virus.(9) Hence taking this into consideration it can be said that the money spent on Tamiflu was appropriate.
On the contrary it can be argued that to what extent does health care expenditure yields health benefits. In the health care organisations the availability of resources are often limited to meet the demands and hence the resources have to be managed by prioritising which health care services are to be provided. In UK cardiovascular disorder is one of the biggest killers and is responsible for NHS expenditure of £30 billion annually (10). Alcohol consumption is another highly considerable heath issue in the UK. It was estimated that alcohol abuse was responsible for higher number of deaths in the UK and cost the NHS £3 billion in 2005-06 (11). Obesity and overweight is another overwhelming problem in the UK the NHS has spent nearly £47.9 millions in 2007 on anti-obesity drugs to control Britain's obesity epidemic (12). NHS has also spent £33 million on smoking cessation services between April and September 2008 (13). Britain spends more on cancer than any other major European countries; NHS has spent £4.35 billion on cancer in England. (14). Hence looking at these huge figures of money spent on some of these diseases it can be analysed that NHS is working efficiently to reduce the countries mortality rate. However the main cause of death in UK is cardiovascular disease, it accounted for 198, 000 deaths in 2007, next to which is cancer. One in four die of cancer, it accounts for 30 percent of death in males and 25 percent in females. The most common cancers are breast, lung, colorectal and prostate cancer and these four common cancers are responsible for half of the 127,800 deaths from cancers in 2007. Smoking and alcohol abuse are also greatest threat to British population. There were 8,724 alcohol related deaths in 2007 and it is estimated that on an average there are 106,000 smoking related deaths per year in UK. (15).
Another cause of mortality in UK is seasonal influenza, thousands of people die every year due to influenza. Millions of people died in the previous influenza pandemics. However in comparison to the previous influenza pandemics swine-flu was found to be less lethal than estimated. The estimated deaths due to swine-flu was investigated and was found that the fatality rate was 26 per 100 000. It was found that there were 138 deaths from estimated 540 000 cases between June to November 2009 and maximum number of deaths were in patients aged over 65 years and with pre-existing long term disorders. This research suggests that the mortality rates were much lesser compared to twentieth century flu pandemic (16).
Influenza virus changes constantly hence the virological and disease surveillance are investigating to detect the impact of the disease and the circulating strains. After stocking huge quantities of Tamiflu the researchers have found that due to frequent use of the drug the H1N1 virus has undergone a basic mutation due to which it has now developed resistance towards the antiviral drug Tamiflu(4*). This feature of the virus should have been considered by the NHS from the previous knowledge gained from the influenza pandemics and should have used the other available antiviral drug Relenza to which the virus still retains it susceptibility or both the neuraminidase inhibitors Tamiflu and Relenza should have been used in combination.(5*) Alternative therapies should have been developed, antiviral drugs such as interferons or ribavirin possess anti-influenza activity in humans moreover a number of nonantiviral drugs such as statins, macrolide antibiotics, gemfibrozil and acetylsalicylic acid or natural products like flavonoids, flavones and polyphenol also have properties to control virus replication and respiratory inflammation caused by influenza A viruses which help to decrease morbidity and mortality resulting from influenza.(6*) And also the vaccination should have been developed at the earliest onset of the pandemic, the vaccines were not available in the market till late November or early December. Hence the money spent on Tamiflu should have been spent by NHS on development of vaccination and firstly protect the highly risk group of population.
In conclusion, for a large health care organisation like NHS with limited resources and whose ultimate aim is total patient care and safety, it is really tough to decide how to utilise its funds for the benefits of the population. Hence in June 2009 when WHO announced H1N1 influenza pandemic the NHS made necessary efforts to stockpile larger stocks of Tamiflu for the British population to avoid any shortage during the pandemic by spending approximately £100 million on it. However the NHS did not consider the nature of the influenza virus and the consequences if the H1N1 influenza virus develops resistance to the infection. Hence instead of spending huge amounts on Tamiflu the government should have utilised it in the development of appropriate vaccine for the swine-flu and made it available to the population at the earliest breakout of the pandemic. And also the government should have taken measures to provide proper information to the public on the status of the H1N1 pandemic to achieve a broad awareness about the potential risks during the pandemic and secondly protect the highly risk group of population with prophylaxis and vaccinations at the earliest. Fortunately the H1N1/2009 pandemic was not as lethal as the previous pandemics and there were only 138 confirmed deaths due to swine-flu throughout UK which are in fact much lesser number compared to even normal seasonal flu annually in UK. In contrast to that the highest rate of mortality in UK are due to cardiovascular disorders, cancers, obesity, smoking and alcohol abuse. And the main areas which need to be focussed are smoking during pregnancy and teenage, teenage contraception, sexual heath and drug abuse. Hence the money could have better spent on some of these areas. However it is always better for NHS to be prepared for the future pandemic situations and spend money on the research and develop a vaccine at the earliest onset of pandemic and protect the population beforehand because protection is always better than cure.