The Opinion Pages

Op-Ed Contributor

Influenza: The next TB?

By EMMA CAMMANN and NEHA SHAH

Spring 1882
Robert Koch
presents his
findings on the
infectious cause
of tuberculosis.
Consumption,"
as it was then
known, becomes
a curable
disease.

April 22nd, 2015

Fall 1943
Scientists
affiliated with
Rutgers
University first
isolate
streptomycin,
the antibiotic
that will become
the first
treatment for
tuberculosis.

Present Day
Despite a
comprehensive
understanding of
the disease and 70
years of
widespread
treatment efforts,
about of the
world's population
is still infected
with Tuberculosis.

These statistics6, 10 represent what is one of the few fundamental failures of modern
medicine. We are unable to eradicate Tuberculosis not because it is difficult to treat,
but because our society is too lazy to treat it correctly. Years of unregulated
treatment have led to the creation of multidrug-resistant TB, which is ultimately
why we face such high rates of infection today. If we do not learn from these
mistakes, influenza could become the next TB. Widespread and unregulated use of
antivirals could quickly lead to resistant influenza strains, to which we will have no
defense if they evolve into more damaging pandemic-like strains. Seasonal
influenza policy is inextricably tied to pandemic influenza policy, and the use of
antivirals and evolving drug resistance lies at the heart of this intersection.
Over the past few years, drug resistance has become something of a political
buzzword; the Obama administration has done an excellent job of raising awareness
about antibiotic resistance while in office.1 However, bacterial resistance to
antibiotics is not the only type of drug resistance our society should be concerned
with. Just as extended antibiotic treatments can give rise to superbugs such as
MRSA1, and improper use of TB medication can give rise to multi-drug resistant
tuberculosis,6 overuse of antiviral influenza medication can result in drug resistant
flu.7
In an effort to prevent a rise in antiviral-resistant influenza in the US, we have
recently been involved in the composition of an updated seasonal influenza policy.
the Seasonal Influenza Policy Reform Act, which was brought to Congress in March
of this year, advocates for a large-scale overhaul of current influenza policy. The act
controversially limits antiviral use to members of high-risk populations such as
people over the age of 65, children under the age of 5, pregnant women, and those
with certain chronic health conditions. However, many average Americans will no

longer be able to obtain these drugs. Understandably, members of these populations

are speaking out. We would like to put the publics mind at ease.
As scientists, we are often perceived as overly cautious. Before you write us off as
reactionaries, know that much of our concern is rooted in historical fact; in the US,
overuse of a class of antivirals called the amantadines has already resulted in drug
resistant flu viruses. Although 1960s scientific innovation culminated with one giant
leap for mankind, strides were also made in the field of antiviral influenza
treatment. In October of 1966, the FDA approved a class of drugs called the
amantadines as a method of severe influenza prevention. 3 Amantadine and its cousin
rimantadine were then regularly prescribed to high-risk patients for the remainder of
the 20th century, despite the fact that amantadine-resistant flu strains began being
detected not long after the introduction of the drug.7 By the beginning of the 21st
century, approximately 90 percent of the viruses plaguing the country were resistant
to amantadine,3 and by the 2005-6 flu season, the drugs were so ineffective that the
CDC removed them from the list of recommended influenza treatments. 3 It is
estimated that 100% of the flu currently in circulation is resistant to this once potent
drug.4 Therefore if todays prevalent antiviral drugs, such as Tamaflu , continue
to be administered with their current frequency, it is not a stretch to think all
strains of influenza will eventually become resistant to them as well.
Although Tamaflu is now a household name, back in the early 2000s, it was little
more than a drug listed on emergency stockpile inventories and examined in peerreviewed journal articles. Officially patented in 1999, Tamaflu, or oseltamavir, was
only really made available to the general public following the 2009 outbreak of
H1N1.2 Prior to Swine flu, Tamaflu was only approved for pandemic situations and
patients who had been hospitalized with influenza. 2 However, over the course of the
2009-2010 flu season, American policy regarding antiviral use became less and less
rigid. For example, a fact sheet published by the CDC that year advises physicians:
All hospitalized patients...moderately ill patients...patients who
appear to be getting worse...and some people without risk
factors [for severe influenza] may benefit from antivirals.8
In an effort to reassure the general public, our government allowed for vague
regulations around antivirals. In effect, they prioritized our feelings of security over
our actual security.
Although in general we disagree with the vagueness of the antiviral policy
surrounding H1N1, there is something to be said for preventing widespread panic.
Although the response to H1N1 is now generally seen as an overreaction, 5 at the time,
people thought it could become the next Spanish Flu. 11 Therefore, what is truly
appalling about 2009-10 flu policy is its legacy. Weve transitioned from viewing
antivirals as a pandemic panic suppressor to an everyday flu cure. We currently
prescribe antivirals as if we were still in pandemic mode, giving treatment to anyone
within 48 hours of the onset their flu symptoms.4 Keep in mind we have not been in a
pandemic since April of 2010.9 Part of the problem stems from our government's
seeming inability to move at anything faster than a glacial pace. Baring certain crisis
situations, science policy are viewed as extraneous, something that can come after

other issues have been resolved. Therefore, instead of updating influenza policy after
the end of 2009-10 flu season, the government was content to allow widespread
antiviral use to persist.
Instead of allowing the complacency of our government to dictate the future of our
nations health, it is time to learn from our mistakes and write health policy that
reflects the science behind influenza. Recently, the Seasonal Influenza Policy Reform
Act has been condemned as altruistic to a fault. While we agree that our policy
advocates for a certain brand of altruism, we would like to deny firmly the claim that
this is a bad thing. Yes, altruistic approaches to medicine are not usually employed
by primary care physicians. The Hippocratic oath declares that we may first do no
harm, not to the human population, but to the people sitting in our exam rooms.
People have a hard time with doctors refusing to prescribe treatments, let alone a
treatment that is neither dangerous nor controversial. If antiviral influenza
medications are in peoples best interest, they cannot comprehend why they should
not be allowed to take it. We have seen altruism in the American health care system
in the form of elective procedures; blood, bone marrow, and organ donations all take
place at the expense of the original donor. However, removal of antiviral medication
from the arsenal of treatments currently available to treat seasonal flu would be
forced altruism on a scale that has not previously been observed. It would mean
consenting to suffer through a few more grueling days of flu when there are
treatments that could make life easier. It would mean thousands of Americans
putting their own health beneath that of people they may never meet.
Americans are not typically ones to forgo their own best treatment option--cancer
patients will sell their homes to try experimental drugs that may not work. However,
we forget that altruism permeates many other facets of American society. It is written
in the history of our mandatory draft policy, our tax law, our civil rights movements,
our unions. We prioritize the good of larger groups of American people over our own
personal well-being every time we enlist or pay taxes or go on strike or refuse to
work. American history has been made by individuals jeopardizing their financial,
social, and/or physical well-being; who is to say we should not do so again? By
constraining our access to antivirals, we will not only be working toward protecting
future generations of Americans, but we will also be speaking volumes about the
innovation and discipline of Americans today. Rarely does our government have the
wherewithal to anticipate and prevent a problem before it arises. Today, we have an
opportunity to change that.
In America, the average cost to attend a private 4-year university is about $125,000.
The average cost to treat a single case of multidrug-resistant tuberculosis is
$134,000.10 Unless we want to start paying college tuitions every time we come down
with the flu, we should make a conscious effort to limit the use of antiviral influenza
treatments in the general population. Although it may take years for influenza to
become the burden that TB is today, we cant wait until that point to act. The time is
now.

Works Cited
1. Executive Office of the President President's Council of Advisors on
Science and Technology. (2014, September). Report to the President on
Combating Antibiotic Resistance [PDF]. Retrieved from
https://www.whitehouse.gov/sites/default/files/microsites/ostp/PCAST/
pcast_carb_report_sept2014.pdf
2. Fiore, A. E., Shay, D. K., Haber, P., Iskander, J. K., Uyeki, T. M., Mootrey,
G., . . . Cox, N. J. (2007, June). Recommendations of the Advisory
Committee on Immunization Practices. Retrieved from
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5606a1.htm
3. Hayden, F. G. (2006). Antiviral Resistance in Influenza Viruses
Implications for Management and Pandemic Response [PDF]. New
England Journal of Medicine, 354(8), 785-788. Retrieved from
http://www.col.opsoms.org/prevencion/influenza/vacunacion/influenza_resistencia_antivira
les.pdf
4. Influenza: Use of Antivirals. (2014, December 1). Retrieved April 28, 2015,
from Center for Disease Control and Prevention website:
http://www.cdc.gov/flu/professionals/antivirals/antiviral-useinfluenza.htm
5. McNeil, D. G., Jr. (2011, March 10). Response of W.H.O. to Swine Flu Is
Criticized. The New York Times, Money and Policy, p. A8. Retrieved from
http://www.nytimes.com/2011/03/11/health/policy/11flu.html
6. Keshavjee, S., & Farmer, P. E. (2012). Tuberculosis, Drug Resistance, and
the History of Modern Medicine. New England Journal of Medicine, 367,
931-936. http://dx.doi.org/10.1056/NEJMra1205429
7. Poland, G. A., Jacobson, R. M. & Ovsyannikova, I. G. Influenza virus
resistance to antiviral agents: a plea for rational use. Clin. Infect. Dis. 48,
12546 (2009).
8. Quick Facts for Clinicians on Antiviral Treatments for 2009 H1N1 [Fact
sheet]. (2009, November 4). Retrieved April 28, 2015, from Center for
Disease Control and Prevention website:
http://www.cdc.gov/h1n1flu/antivirals/facts_clinicians.htm
9. The 2009 H1N1 Pandemic: Summary Highlights, April 2009-April 2010.
(2010, June 16). Retrieved April 28, 2015, from Center for Disease Control
and Prevention website: http://www.cdc.gov/h1n1flu/cdcresponse.htm

10. Treatment Practices, Outcomes, and Costs of Multidrug-Resistant and

Extensively Drug-Resistant Tuberculosis, United States, 20052007 Volume 20, Number 5May 2014 - Emerging Infectious Disease journal CDC. at http://wwwnc.cdc.gov/eid/article/20/5/13-1037_article
11. WHO Press Conference on H1N1 [Audio file]. (2009, June 11). Retrieved
from
http://terrance.who.int/mediacentre/audio/press_briefings/PC_11JJUN
2009_H1N1_influenza.mp3